22 Chapter 149 :: Wound Healing
:: Afsaneh Alavi & Robert S. Kirsner
AT-A-GLANCE
■ While acute and chronic wounds are different, all
chronic wounds start as an acute wound.
■ In acute wounds, there is an orderly progression
from injury to coagulation, inflammation, cell and
Part 22
matrix proliferation, cell migration, and tissue
remodeling.
■ In the initial phases, a wide range of growth
factors, including platelet-derived growth
::
factor and transforming growth factor-β1,
Vascular Diseases
play an important role. In the proliferation/
migration and modeling phases, tissue matrix
metalloproteinases (MMPs), integrins, basic
fibroblast growth factor, and epidermal growth
factor are critical. MMP-1, MMP-9, and MMP-10
are essential for remodeling.
■ For acute wounds, moist wounds heal faster, and a
variety of wound dressings are available, including
hydrogels, polyurethane films, hydrocolloids,
foams, alginates, superabsorbent dressings, and
collagen-based products.
■ In chronic wounds, the linear progression
between the sequential phases of acute wound
healing is lost. Chronic wounds are often the
result of ischemia, pressure, and infection;
healing, in part, is dependent on addressing
these factors.
■ Healing after skin grafting is also different,
as it depends on revascularization, either
neovascularization or inosculation.
Wound healing involves a complex but overlapping
sequential series of events aimed at barrier restoration,
from hemostasis to inflammation, proliferation, and
remodeling. Many mediators, such as platelets, neutro-
phils, macrophages, cytokines, growth factors, matrix
metalloproteinases, and their inhibitors regulate these
events.1 Some wounds fail to move through these
stages in an orderly and timely fashion and become
chronic wounds. All these components play a role in
healing, and alteration in one or more of these com-
ponents may impair healing and/or lead to abnormal
scar formation, such as a hypertrophic scar or keloid.2
Wounds can be categorized by the depth of the wound,
which helps predict the amount of scarring that will
occur. Greater scarring occurs in full-thickness versus
partial or spilt-thickness wounds. Figure 149-1 out-
lines these differences.
Kang_CH149_p2700-2718.indd 2700
DIFFERENT TYPES OF
WOUND HEALING
Primary healing, also called healing by primary or first
intention, is the closure of the wound soon after wound
creation, as seen in surgical wounds and clean lacera-
tions. Wound closure is aided by approximation of the
wound edges using sutures, glues, tapes, or mechani-
cal devices, and in side-to-side closure and with grafts
and flaps.
Delayed primary healing is the slightly delayed closure
of a wound, typically by a few days. As an example, a
contaminated wound may first be treated with anti-
microbials to assure eradication of bacteria that might
delay healing.
In healing by secondary intention, the open wound
heals through a process that includes granulation
tissue formation and epithelialization. Commonly
employed after an excessive loss of soft tissue, such as
major trauma or severe burns, the large defect requires
ingrowth of granulation tissue and extracellular matrix
(ECM) formation. Myofibroblasts plays a major role in
this type of healing,1 appearing 3 days after the injury
and reaching a maximum level 10 to 21 days postin-
jury. Secondary intention healing may result in wound
contracture and can cause functional restriction.
Tertiary intention occurs when a wound originally
closed by primary intention dehisces and then heals
by secondary intention.
The time to complete healing depends on many
factors such as the depth of the wound, location of
the wound (eg, facial wounds heal faster than acral
wounds), vascular supply, presence of infection, and
wound shape (smaller diameter wounds heal faster
than larger diameter wounds of the same size/area.)3
MECHANISMS OF
WOUND HEALING
PHASES OF WOUND HEALING
Tissue injury triggers a cascade of sequential, overlap-
ping events that have been categorized into several
phases, including: (a) coagulation, (b) the inflamma-
tory phase, (c) the proliferative (and migratory) phase,
and (d) the remodeling phase. Figure 149-2 illustrates
these phases in diagrammatic form, and Fig. 149-3
shows specific events that take place during the vari-
ous phases. The cell types primarily involved in wound
04/12/18 9:34 am
 Split- and full-thickness wound areas
healing are platelets, neutrophils, and macrophages,
fibroblasts, endothelial cells, and epithelial cells. More
22
recently, increasing importance is accumulating for the
Full-thickness Split-thickness
wound wound role, either directly or indirectly, of lymphocytes.4,5

COAGULATION
Immediately after injury, disruption of blood vessels
Epidermis
leads to local release of blood cells and bloodborne
elements, resulting in clot formation and activation
of the intrinsic and extrinsic coagulation cascade.3
While the blood clot within the vessel lumen provides
Dermis hemostasis, the clot within the injury site acts as a
provisional matrix for cell migration, leads to further

Chapter 149 :: Wound Healing

Subcutaneous
tissue
Figure 149-1 Diagrammatic representation of the skin,
with 2 inverted triangles representing either a split-
thickness or full-thickness wound. Extending the injury
below the reservoir of keratinocytes present in skin
appendages (full-thickness wound) removes the capa-
bility of the keratinocytes to populate the defect from
within the wound bed, which means healing has to
occur from the wound edges and more scarring takes
place.
formation of ECM,6 and provides a reservoir for cyto-
kines and growth factors.7,8 Platelets degranulate and
release α granules which secret growth factors includ-
ing platelet-derived growth factors, insulin-like growth
factors, epidermal growth factors, transforming growth
factor-β, and platelet factor 4. Platelets also release a
number of chemotactic factors that attract other plate-
lets, leukocytes, and fibroblasts to the site of injury.8,9
The clot also contains fibrin, fibronectin, vitronectin, von
Willebrand factor, and thrombospondin, which provide
a matrix for cell migration. Vasoactive amines released
from platelets, such as serotonin, facilitate cell migration
by increased microvascular permeability. Hageman fac-
tor XII is a specific enzyme released following platelet
aggregation to initiate the intrinsic coagulation cascade.
Prothrombin transforms into thrombin, converting sol-
uble fibrinogen to insoluble fibrin. Additionally, injured

The different phases of wound healing

Phases of healing Main cell types involved

Coagulation Platelets
phase

Inflammatory Platelets
phase Macrophages
Neutrophils

Macrophages
Migratory/proliferative Fibroblasts
phase Epithelial cells
Endothelial cells

Remodeling Fibroblasts
phase Myofibroblasts

Injury Hours Days Weeks

2701
Figure 149-2 Schematic, different of the different phases of wound healing.

Kang_CH149_p2700-2718.indd 2701 04/12/18 9:34 am

22 The phases of wound healing and key cells and events involved

Time Phases Main cell types Specific events

Coagulation
Platelet aggregation and release of
Fibrin plug formation,
Platelets fibrinogen fragments and other
release of growth factors,
pro-inflammatory mediators
cytokines, hypoxia
Hours

Inflammatory Selectins slow down blood cells + binding

Neutrophils
Cell recruitment and to integrins diapedesis
Monocytes
chemotaxis, wound Hemidesomosome break-down
Macrophages
debridement keritinocyte migration
Days
Part 22

Migratory/proliferative
Keratinocytes Cross-talk between MMPs, integrins,
Epidermal resurfacing, Fibroblasts cells, cytokines cell migration,
fibroplasia, angiogenesis, Endothelial cells ECM production
ECM deposition, contraction
::
Vascular Diseases

Remodeling Phenotypic switch to

Scar formation and revision, Myofibroblasts myofibroblasts from
Weeks ECM degredation, further fibroblasts
to contraction and tensile strength
months

Figure 149-3 The phases of wound healing, and key cells and events involved. (Reprinted from Falanga V. Wound healing
and its impairment in the diabetic foot. The Lancet. 2005;366:1736-1743; with permission. Copyright © Elsevier.)

tissue releases a tissue factor that activates the extrinsic
coagulation pathway.9
INFLAMMATION
Inflammation begins with activation of classic and
alternative complement cascades and subsequent
neutrophil infiltration to the wound site within 24
to 48 hours of injury. White cells have multiple func-
tions, including phagocytosis of necrotic material and
bacteria, as well as the production of certain critical
cytokines.10,11 Leukocytes adhere to the adjacent blood
vessels (margination) and actively move through
the vessel wall via diapedesis. Leukocytes release
enzymes and oxygen-derived free radicals. After the
first few days, the constituency of white cells changes
as neutrophils are replaced by macrophages.12
Macrophages, often considered the most important
regulatory cells in the wound healing inflammatory
process, typically appear in the wound site 72 hours
after the injury. Macrophages, key regulator cells for
repair, are the main phagocytic cells and release pro-
teolytic enzymes such as a variety of collagenases.
Macrophages also produce growth factors responsible
for the smooth muscle proliferation and endothelial
cell and fibroblast proliferation, all of which contribute
to ECM production. This hypoxic environment is asso-
ciated with high levels of proteases and low pH, both
of which contribute to activation of growth factors.11
2702 Monocytes are attracted to the injury site by kallikrein,
fibrinopeptides, and fibrin-degradation products; some
of these same chemoattractants are also responsible
for recruitment of neutrophils.13,14 Other more specific
chemoattractants further recruit monocytes, includ-
ing collagen fragments, fibronectin, elastin, and trans-
forming growth factor (TGF)-β1. Monocytes undergo a
phenotypic change to tissue macrophages critical for
the progression of healing.15,16 Macrophages release che-
motactic factors to attract fibroblasts to the wound area.
Importantly, they display impressive plasticity, and at
least 2 subsets of macrophages exist and have distinct
phenotypes in various stages of healing (see below).
They also produce a variety of growth factors, such
as platelet-derived growth factor (PDGF), fibroblast
growth factors (FGFs), and vascular endothelial growth
factors (VEGFs), as well as TGF-β and TGF-α. Altera-
tions in tissue macrophages or circulating monocytes
lead to poor intrinsic debridement, delay proliferation
of fibroblasts, and allow for inadequate angiogenesis
and overall poor healing.17
Macrophages are divided into M1 (or classically
activated) and M2 (or alternatively activated) mac-
rophages. M1 phenotype macrophages are activated
by interferon-γ and tumor necrosis factor (TNF)-α
following wound formation. They release interleu-
kin (IL)-12 and promote a proinflammatory T-helper
(Th)-1 immune response early on. Subsequently, M2
macrophages, activated by IL-4 and IL-13, work to
downregulate inflammation by releasing antiinflam-
matory cytokines such as IL-10. These M2 macro-
phages present later in healing during granulation
tissue formation.17-19

Kang_CH149_p2700-2718.indd 2702 04/12/18 9:34 am

 ABNORMAL INFLAMMATORY PHASE
Immediately after injury, local vasodilation, extrava-
sation of blood and fluid, and lymphatic drainage
blockage (in some cases) can lead to cardinal symp-
toms of inflammation such as heat, redness, pain,
and swelling. The acute inflammatory response may
last 2 weeks; however, prolongation of inflammation
(chronic inflammation) may delay healing.20
With chronic inflammation, the wound often con-
tains necrotic tissue and pathogenic organisms. In
this case, granulocytes disappear and mononuclear
cells, particularly monocytes, lymphocytes, and mac-
rophages, become the predominant cells at the site of
inflammation.
From the clinical standpoint, certain wounds, such
as pyoderma gangrenosum, have excessive inflamma-
tion and treatment, with corticosteroids for example,
leads to downregulation of inflammation and healing.
Fine-tuning the inflammatory response may represent
a therapeutic target for other wounds as well.21
PROLIFERATION
The proliferative phase, characterized by fibroblast
migration, deposition of ECM, and formation of gran-
ulation tissue, normally starts at about day 3 after
wounding and lasts for 2 to 4 weeks. Figure 149-4
illustrates events that occur in the proliferative/migra-
tory and remodeling phases. An important event in
this phase is reepithelialization. This critical event also
involves migration of keratinocytes and the interde-
pendence between keratinocyte movement over the
provisional fibrin matrix, recruitment of fibroblasts
and endothelial cells, and ECM formation.22
Growth factors, such as PDGF and TGF-β, attract
fibroblasts to the wound. Fibroblasts subsequently
Epidermal migration
Fibrin plug
Hemidesmosome
disassembly/keratinocyte migration
Angiogenesis
ECM deposition stimulated by
growth factors, cytokines
Figure 149-4 Schematic, using a modified photomicrograph section, of the events taking place shortly after injury, includ-
ing formation of a fibrin plug, epidermal migration, and extracellular matrix deposition.
Kang_CH149_p2700-2718.indd 2703
proliferate and produce a matrix consisting of fibronec-
tin and hyaluronan initially, and collagen and proteo-
22
glycans later. These components are essential for new
ECM formation and tissue repair. ECM serves both as
turgor of soft tissue and as a scaffold and regulator of
cell adhesion and growth. It is made of an interstitial
matrix of adhesive proteins embedded in proteogly-
can and glycosaminoglycan gel as well as the fibrinous
structural proteins collagen and elastin.23
Fibroblasts make collagen, the most abundant
protein in the body, and noncollagenous proteins.
During the proliferative phase, collagen synthesis
is induced by PDGF, basic FGF (bFGF), TGF-β, IL-1,
and TNF. There are 18 different types of collagen.
Chapter 149 :: Wound Healing
Fibrillar collagens, such as I, III, and V, form the con-
nective tissue in the healing wound, and nonfibril-
lar forms, such as collagen IV, form the basement
membrane.
Collagen gene expression is regulated by multiple
factors such as TGF-β and FGF. TGF-β stimulates pro-
duction of collagen I and collagen III. The overexpres-
sion of matrix metalloproteinases (MMPs) and/or
impaired counteraction of tissue inhibitor of metal-
loproteinases (TIMPs) contributes to delayed healing
and fibrosis. Interaction between these cytokines is
extremely important. The fibroblasts in patients with
longstanding diabetic foot ulcers show a decreased
response to TGF-β1 and decreased expression of TGF-β
receptors. Although overexpression may be problem-
atic, tissue matrix MMPs and other enzymes, such
as plasminogen activator inhibitor, are critical to the
movement of cells through provisional structural
matrix components.
Adhesive proteins, including fibronectin (FN), lam-
inin, thrombospondin, and integrins, help guide cel-
lular migration.24 FN is a large heterodimer linked to
cell surfaces, basal membranes, and the ECM. FN can
attach to ECM components such as collagen, fibrin,
Keratinocyte proliferative burst
Hair follicle keratinocyte
contribution after injury
Cell migration and recruitment
2703
04/12/18 9:35 am
22 and proteoglycan, or to integrins and directly mediate
the cell migration. FN also activates intracellular sig-
naling pathways to increase the sensitivity of certain
cells, such as endothelial cells, to growth factors.25
Integrins are important in cell–cell and cell–matrix
adhesion, serving to regulate interaction between
ECM and the cytoskeleton. The integrins, consisting
of at least 24 αβ heterodimers (18 α and 8 β subunits),
are transmembrane cell surface receptors that bind the
ECM to cytoskeletal structures.25 The integrin profile is
very dynamic during the repair process. For example,
dermal fibroblasts undergo a switch from α2 to α3 and
α5 integrin subunits. As another example, endothelial
cells cannot respond to angiogenic stimuli without
the expression of αvβ5 integrin. Certain polypeptide
Part 22
to a protein backbone that modulate cell growth
and differentiation. Additionally, glycosaminoglycans
without a protein core (hyaluronan) are also important
components of the ECM.
Histopathology of a granulating wound bed shows
proliferation of fibroblasts and capillaries in a loose
ECM. Neovascularization, or formation of new blood
vessels, is characteristic of this stage. Several factors
induce angiogenesis as a part of granulation tissue
development; new capillaries sprout, invading the
fibrin and FN-rich clot. The density of blood ves-
sels is reduced over time with scar formation and as
the wound moves toward the remodeling phase.26
Fibroblast replication and longevity are enhanced in

hypoxia, and low oxygen tension stimulates clonal

growth factors are essential to angiogenesis, including expansion of dermal fibroblasts seeded as single cells.27
bFGF and VEGF.25,26 Table 149-1 highlights the main Moreover, the synthesis of a number of growth factors
cytokines and growth factors shown to play a role in is enhanced in hypoxic cells.
::

the repair process. After a provisional matrix has formed, keratino-

Vascular Diseases

Another constituent of ECM are noncollagenous cytes migrate to epithelize the wound. MMP function
proteins such as proteoglycans, which are glycosami- is critical for allowing keratinocytes at the edge of the
noglycans (dermatan sulfate, heparin sulfate) linked wound to detach from their hemidesmosomal and

TABLE 149-1
The Major Growth Factors Involved in Wound Healing and Their Functions39
GROWTH FACTOR MAJOR SOURCES FUNCTION

Epidermal growth factor (EGF) Platelets, macrophages, fibroblasts Epithelialization

Transforming growth factor
(TGF)-α
TGF-β
Activins
Fibroblast growth factor (FGF)
Platelet-derived growth factor
Vascular endothelial growth
factor (A-E)
Granulocyte-macrophage
colony-stimulating factor
Interleukin (IL)-1
IL-6
2704
Fibroblast proliferation
Keratinocyte proliferation
Angiogenesis
Keratinocytes, macrophages, fibroblasts, Keratinocyte migration
lymphocytes
Macrophages, fibroblasts, keratinocytes, Inflammation, angiogenesis, reepithelialization, connective tissue
platelets regeneration, remodeling
TGF-β1, TGF-β2: promote fibrosis and scar formation
TGF-β3: antiscar properties
Fibroblasts, keratinocytes Epithelialization
Keratinocytes, fibroblasts, smooth muscle FGF-2: granulation tissue formation, reepithelialization, tissue
cells, chondrocytes, endothelial cells, remodeling, fibroblast migration, collagen formation
mast cells FGF-7, FGF-10: increase transcription factors, detoxification of
reactive oxygen species
FGF-7: neovascularization
Platelets, macrophages, vascular Fibroblast proliferation
endothelium, fibroblasts Angiogenesis
Matrix formation
Keratinocytes, endothelial cells, Angiogenesis
fibroblasts, smooth muscle cells,
platelets, neutrophils, macrophages
Macrophages Keratinocyte proliferation
Fibroblasts Epithelialization
Endothelial cells Cell migration
Natural killer cells Chemotaxis
Mast cells Angiogenesis
Monocytes Keratinocyte proliferation
Macrophages Fibroblast proliferation
Keratinocytes Angiogenesis
Neutrophil chemotaxis
Neutrophils Keratinocytes proliferation
Monocytes Neutrophil chemotaxis

Kang_CH149_p2700-2718.indd 2704 04/12/18 9:35 am

 desmosomal attachments and migrate across the pro-
visional matrix. Other proteins play important roles,
including plasminogen activator inhibitor, a serine
protein inhibitor that functions as the main inhibitor of
tissue plasminogen activator, and urokinase plasmino-
gen activator.28
Upregulation of tissue plasminogen activator and
urokinase plasminogen activator are important for
keratinocyte migration, which may depend on cross-
talk and interactions between α3β1, keratinocytes, and
collagen. These events lead to the induction of MMP-1
(collagenase-1 or interstitial collagenase), which is
important for keratinocyte migration and epitheliali-
zation.6 MMP-9 plays a fundamental role in “cutting”
Type IV and Type VII collagen, which are essential
components of the basement membrane and anchor-
ing fibrils, and promotes inflammation and neutro-
phil migration. For keratinocyte migration to occur,
a necessity exists to break down these complex struc-
tures anchoring the basal keratinocytes to the basement
membrane and neighboring keratinocytes. This pro-
cess is as complex as the structure itself, and involves
interactions between MMPs, integrins, growth factors,
and structural proteins. In the normal resting state,
laminin-332 is bound to α6β4-integrin, the latter linking
the intracellular keratin filaments of keratinocytes to
the basement membrane. As a result of the interaction
of integrins (including their phosphorylation status)
with the ECM and their receptor clustering on the sur-
face of keratinocytes, important morphologic changes,
such as lamellipodia formation, occur for keratinocyte
locomotion.29-31 Migration of keratinocytes is essential
for resurfacing of the wound.26,32
Keratinocytes begin to migrate from the wound
edge and from skin appendages within the first
24 hours. The hair bulge, the germinative portion
of the hair, is an important reservoir for keratino-
cytes in partial thickness wounds. A series of events
in migration involves elongation of keratinocytes,
development of pseudopod-like projection of lamel-
lipodia, loss of cell-to-cell adhesion, retraction of
intracellular tonofilaments, and formation of actin
filaments at the edge of the cytoplasm, all of which
occur while the proliferative ability of keratinocytes
is inhibited.
To facilitate migration, there is a marked increase in
mitotic activity within the basal epithelial cells of the
wound edge from 12 hours, extending lamellipodia
along the wound edges. Subsequently keratinocytes
lose their attachment to the underlying dermis to
migrate in a leapfrog fashion. Eventually a new base-
ment membrane forms and further growth and dif-
ferentiation of epithelial cells establishes the stratified
epithelium. The process of epithelialization is facili-
tated in a moist environment, serving as the biologic
basis for modern occlusive dressings.
REMODELING
The final phase, remodeling, is typically the lon-
gest phase, involving the continuous synthesis and
Kang_CH149_p2700-2718.indd 2705
breakdown of collagen as the ECM evolves. Start-
ing early in the healing process, wound remodeling
22
may continue for months. The interaction of ECM
and fibroblasts causes wound contraction and is
influenced by multiple cytokines, including TGF-β,
PDGF and bFGF.
The remodeling of the ECM, as well as the move-
ment of cells, is highly dependent on MMPs and serine
proteases.33 An important component of this depen-
dence on MMPs is MMP-driven degradation of ECM
and the resulting exposure of selective bioactive ECM
segments that influence cell behavior, including migra-
tion and proliferation.6,33
Metalloproteinases produced by fibroblasts, neu-
Chapter 149 :: Wound Healing
trophils, keratinocytes, and macrophages, include
interstitial collagenase (degrades collagen Types I,
II, and III), gelatinases (degrades denatured collagen
and FN) and stromelysins (degrades proteoglycans,
laminin, FN, and amorphous collagen). MMP-10
(stromelysin) breaks down other noncollagenous
ECM components and facilitates migration.6,11,34 Other
mediators, such as thymosin-β, upregulate MMPs
during wound repair.35 The activity of MMPs are
tightly regulated because they may degrade essential
collagens and impair healing. They are activated by
certain proteins (plasmin) and inhibited by specific
tissue inhibitors of metalloproteinases. Table 149-2
summarizes certain MMPs and their prominent effect
in wound healing.
During the remodeling process, a phenotypic switch
occurs in certain cell subpopulations from fibroblasts
to myofibroblasts.36 Although the early process of heal-
ing relies largely on matrix accumulation, which, in
turn, facilitates cell migration, later healing requires a
dampening of ECM formation to a level that at least
approximates the preinjury state. However, the remod-
eling phase is more than a breakdown of excess mac-
romolecules formed during the proliferative phase of
wound healing. During this phase, cells within the
wound are returned to a stable phenotype, ECM mate-
rial is altered (ie, collagen Type III to collagen Type I),
and granulation tissue disappears.11,26 Granulation tis-
sue evolves to a scar composed of less-active fibro-
blasts, dense collagen, and fragments of elastic tissue
along with the rest of ECM. Scar matures and the ten-
sile strength increases to a maximum of 80% strength
of noninjured skin. In full-thickness wounds, contrac-
tion is responsible for 40% of the decrease in wound
size.
FETAL HEALING
During early embryogenesis, wounded fetal tissue
heals without fibrosis. Regeneration, as opposed
to repair, occurs. Later in embryogenesis (last tri-
mester) and after childbirth, repair (as opposed to
regeneration) occurs, with resulting fibrosis. Among
factors that affect scarring, fibromodulin is a small
glycoprotein that mediates scarless healing in fetal 2705
skin.37
04/12/18 9:35 am
22 TABLE 149-2
Matrix Metalloproteinases Proteinases with Well-Established,
Functional Effects on Wound Healing
CORRESPONDING
EFFECT COMMON NAMES MMP DESIGNATION SOME SPECIFIC EFFECTS

Keratinocyte prolifera- Collagenase 1 MMP-1 Increased migration

tion and migration Gelatinase A MMP-2  
    Stromelysin 2 MMP-10  
Matrilysin-1 MMP-7   
Epilysin MMP-28
Endothelial cell (EC) Collagenase 3 MMP-13 Increases EC migration
migration  Gelatinase A MMP-2 Needed for angiogenesis
  MT1-MMP MMP-14 Needed for angiogenesis
Part 22

Cell migration  Stromelysin 1 MMP-3 Required for excisional

  Stromelysin 2 MMP-10 wounds  
Matrilysin-2 MMP-26
::

Inflammation Collagenase 2 MMP-8 Antiinflammatory

Vascular Diseases

  Gelatinase A MMP-2 Antiinflammatory

  Gelatinase B MMP-9 Promotes inflammation 
  Matrilysin-1 MMP-7
Neutrophil migration Gelatinase B MMP-9  
  MT6-MMP MMP-25 Increases neutrophil
migration
Apoptosis Collagenase 2 MMP-8 Prevents apoptosis
  MT1-MMP MMP-14 Antiapoptotic
  MT2-MMP MMP-15  
  MT6-MMP MMP-25  

MMP, matrix metalloprotease; MT, membrane type.

EGF is secreted in a paracrine fashion by platelets,

GROWTH FACTORS AND
CYTOKINES
Wound healing is regulated by multiple growth fac-
tors and cytokines released at the wound site. Growth
factors are biologically active polypeptides that can
alter the growth, differentiation and metabolism of a
target cell. They are important elements in the healing
of wounds. Table 149-1 lists the major growth factors
and cytokines involved in healing and their respective
roles.38-40 Although potentially important in healing
from a therapeutic standpoint, only PDGF-BB, bFGF,
and granulocyte-macrophage colony-stimulating fac-
tor (GM-CSF) are used clinically in the management of
wounds, and only PDGF is approved for wound heal-
ing by the U.S. Food and Drug Administration (FDA).
EPIDERMAL GROWTH
FACTOR FAMILY
Epidermal growth factor (EGF) family members bind
to a tyrosine kinase transmembrane protein or EGF
receptor.41 EGFR normally localizes throughout the
epidermis with its membranous presence being more
prominent in the basal layer. EGFR plays an important
2706 role in reepithelialization by increasing keratinocyte
proliferation and cell migration.42,43
macrophages and fibroblasts and acts on keratino-
cytes. Faulty location of the EGF receptor may be prob-
lematic in some nonhealing wounds. An in vitro study
demonstrated the presence of EGFR in the cytoplasm,
rather than the extracellular membrane, of cells in
non,healing wounds, suggesting receptor downregu-
lation within chronic wounds.42-44 TGF-α is another
member of the EGF family that is secreted by kerati-
nocytes, macrophages, fibroblasts, and lymphocytes,
and works in an autocrine fashion.45,46 TGF-α induces
expression of keratin 6 and keratin 16 (present in pro-
liferating keratinocytes) and increases keratinocyte
migration.47
TRANSFORMING GROWTH
FACTOR-β FAMILY
TGF-β family members include TGF-β1 to TGF-β3,
bone morphogenic proteins, and activins. TGF-β1,
TGF-β2, and TGF-β3 promote the migration of fibro-
blasts and endothelial cells and deposition of extra-
cellular matrices by fibroblasts during granulation
tissue formation. TGF-β1 predominates in wound
healing.48 Interestingly, TGF-β1 and TGF-β2 promote
fibrosis and scar formation, whereas TGF-β3 has antifi-
brotic properties.49 TGF-β, produced by macrophages,
fibroblasts, keratinocytes, and platelets, is important

Kang_CH149_p2700-2718.indd 2706 04/12/18 9:35 am

 in the wound healing processes of inflammation,
angiogenesis, reepithelialization, and connective tis-
sue regeneration.48,50 TGF-β1 facilitates recruitment of
inflammatory cells, and promotes macrophage medi-
ated debridement and granulation tissue formation.
During reepithelialization, TGF-β1 shifts keratinocyte
integrin expression toward a more migratory sub-
type.51 In the remodeling phase, TGF-β1 plays a major
role in collagen production and inhibits collagen
breakdown by inhibiting MMP-1, MMP-3, and MMP-
9, and promoting TIMP-1.52,53
TGF-β1 plays an important role in the formation
of hypertrophic scars and keloids by overexpression
of connective tissue growth factor.54 In fetal wounds,
deceases in TGF-β1 transcription help explain the scar-
less healing that is seen.55
Activins are members of the TGF-β family produced
by fibroblasts and keratinocytes and play role in reepi-
thelization. Activin inhibits keratinocyte proliferation
and induces terminal differentiation of keratinocytes.
bone morphogenic proteins are another member of
the family involved in keratinocyte differentiation.
Overexpression of bone morphogenic protein-6 is
associated with delayed healing.39,56
FIBROBLAST GROWTH
FACTOR FAMILY
The 3 main members of the FGF family involved in
wound healing are FGF-2, FGF-7, and FGF-10. FGFs
are produced by keratinocytes, fibroblasts, smooth
muscle cells, chondrocytes, endothelial cells, and mast
cells.57 FGF receptors 1 to 4 are tyrosine kinase trans-
membrane proteins that work like EGFR.45
bFGF or FGF-2 plays a role in granulation tissue for-
mation, reepithelialization, and tissue remodeling.58
FGF-2 regulates the synthesis of ECM components,
and facilitates keratinocyte and fibroblast migra-
tion and collagenase formation. bFGF is decreased in
chronic wounds.59
FGF-7 or keratinocyte growth factor-1 and FGF 10
or keratinocyte growth factor-2. FGF-7 and FGF-10 are
secreted in a paracrine fashion, found only on kerati-
nocytes, and have a role in reepithelialization. FGF-7
and FGF-10 increase transcription factors involved
in detoxification of reactive oxygen species. FGF-7 is
a strong mitogen of vascular endothelial cells and is
important during neovascularization.60
PLATELET-DERIVED GROWTH
FACTOR FAMILY
PDGFs, produced by platelets, macrophages, vascu-
lar endothelium, fibroblasts, and keratinocytes, bind
to 2 different transmembrane tyrosine kinase recep-
tors (α and β).61 Upon injury PDGF is released from
degranulating platelets. PDGF, chemotactic for mono-
cytes, macrophages, and neutrophils, is a mitogen for
fibroblasts and smooth muscle cells in vitro. PDGF
also stimulates macrophages to produce growth
Kang_CH149_p2700-2718.indd 2707
factors such as TGF-β.62 PDGF plays an important role
in blood vessel maturation and works synergistically
22
with hypoxia to stimulate VEGF formation in vitro.
However, PDGF angiogenic activity is less than FGF
and VEGF.63 While not directly affecting keratinocyte
migration, PDGF plays role in reepithelialization by
in vitro production of insulin-like growth factor-1 and
thrombospondin-1. PDGF also enhances the prolifera-
tion of fibroblasts and, in turn, the production of ECM.
Recombinant human PDGF-BB (becaplermin) is the
only FDA-approved drug for nonhealing neuropathic
diabetic foot ulcers.64,65
VASCULAR ENDOTHELIAL GROWTH
Chapter 149 :: Wound Healing
FACTOR FAMILY
Members of the VEGF family include VEGF-A to
VEGF-E and placental growth factor.66 VEGF-A, which
is secreted by keratinocytes, endothelial cells, fibro-
blast smooth muscle cells, platelets, neutrophils, and
macrophages, binds to a tyrosine kinase surface recep-
tor that is located on the endothelial surface of blood
vessels, early in wound healing angiogenesis.67 Plate-
lets release VEGF-A upon injury. Macrophages release
VEGF-A directly but also release TNF-α, which induces
VEGF-A expression on keratinocytes and fibroblasts.
Hypoxia is a major stimulus for release of VEGF-A,
and the VEGF-A gradient parallels the hypoxia gradi-
ent. VEGF-A is also involved mainly in the inflamma-
tory stage of wound healing. Placental growth factor is
expressed by keratinocytes and endothelial cells as a
proangiogenic molecule. Placental growth factor stim-
ulates cultured fibroblast migration and stimulates
granulation tissue formation.68
GRANULOCYTE-MONOCYTE
COLONY-STIMULATING FACTOR
GM-CSF has particular importance in the inflamma-
tory stage of wound healing by increasing keratino-
cyte proliferation and enhancing reepithelialization.
GM-CSF promotes proliferation and differentiation
of neutrophils and hence increases host defenses.69
GM-CSF indirectly upregulates IL-6. In 2 studies on
diabetic foot ulcers, in total 67 patients with infected
diabetic foot ulcers were treated either with placebo
or topical GM-CSF. Although GM-CSF improved
neutrophil function and increased absolute neutro-
phil numbers, the addition of topical GM-CSF to
standard care had no additional beneficial clinical
effect.69
PROINFLAMMATORY CYTOKINES
Proinflammatory cytokines, including IL-1, IL-6, and
TNF-α, are upregulated in the inflammatory phase of
wound healing. IL-1 is produced by monocytes, macro-
phages, monocytes, and keratinocytes, with both para-
crine and autocrine functions. IL-1 induces expression 2707
of keratin 6 and keratin 16 in migrating keratinocytes,
04/12/18 9:35 am
22 and activates fibroblasts to secrete FGF-7.70 IL-6 is
produced by neutrophils and monocytes with mito- TABLE 149-3
genic and proliferative effect on keratinocytes and Debridement Techniques
chemoattractive effects on neutrophils. TNF-α and
IL-1β are increased in chronic wounds. The effect of DEBRIDEMENT
TECHNIQUES ADVANTAGES DISADVANTAGES
exogenous TNF is dependent on the concentration
and duration of exposure.70,71 TNF-α at low levels Surgical, sharp (with High speed Painful procedure,
promotes healing by stimulating inflammation and scissors and/or Selectivity expensive
increasing macrophage-produced growth factors, scalpel) Needs skilled
whereas at higher levels TNF-α impairs wound heal- professionals
Contraindicated in
ing by suppressing production of ECM and TIMP and
ischemic tissue and
increasing MMPs. Chronic inflammation stimulates
bleeding disorders
production of TNF-α and IL-1β that synergistically
Enzymatic Low pain Medium cost and low
increases production of MMPs and suppress produc-
(collagenase) selectivity
Part 22

tion of TIMPs.72
Some patients are
allergic to the

CHEMOKINES enzyme preparation

::

Biologic (larval High speed and High cost

Chemokines are a family of small cytokines or signal- therapy) high selectivity Contraindicated in
Vascular Diseases

ing proteins that attract neutrophils to the site. Macro- Medium pain bleeding diathesis
phage chemoattractant protein-1 (or CCL2) is induced and deep, tunneling
by keratinocytes and is chemoattractant for monocyte/ wounds
macrophages, T cells, and mast cells.73 Mechanical (wet Medium speed Painful
Interferon-inducible protein 10 (or CXCL10) is to dry dressings, Nonselective
another cytokine that negatively impacts wound heal- hydrotherapy,
ing. Interferon-inducible protein 10 inhibits migration ultrasonography)

of fibroblasts. IL-8 increases keratinocyte migration and Autolytic Low pain Low speed
proliferation, and is a chemoattractant of neutrophils.74 (endogenous Low selectivity
enzymes with Relatively high cost
moisture-retentive Contraindicated in

CLINICAL ISSUES IN
dressings) infected wounds
Risk of exposed bone/

WOUND HEALING
tendon and friable
skin

WOUND BED PREPARATION

Although the majority of wounds heal in a timely
manner, a proportion of wounds stall and do not fol-
low the stages of healing. A nonhealing wound needs
wound bed preparation to promote healing. The con-
cept of wound bed preparation has been summarized
using the pneumonic TIME: Tissue debridement,
Infection/inflammation, Moisture balance, Epithelia
edge tissue.21,32,75
Tissue debridement plays a key role in tissue prep-
aration by removing nonviable tissue and patho-
genic bacteria. Multiple techniques to debride exist,
including surgical, enzymatic, biologic, mechanical,
and autolytic techniques. Newer tools, such as low-
frequency ultrasound and hydrosurgery devices, have
been developed.76 Table 149-3 lists techniques used for
tissue debridement.
Treating infection and inflammation implies assess-
ment of the need for topical antiseptic and/or systemic
antibiotic use to control infection and subsequent
inflammation. Although inflammation is a physiologic
process in wound healing, inappropriate inflamma-
tion can cause delayed healing. Infection may be clas-
sically seen as a host response, as in cellulitis. Bacteria
2708 may also delay healing through formation of biofilm,
seen in 60% of chronic wounds. Biofilms are colonies
of microorganisms that protect themselves through
community living, in part by a surrounding glycocalyx
(Fig. 149-5). Disruption of biofilms with debridement,
with or without antimicrobial agents, helps alleviate
persistent inflammation.77
The term antimicrobial includes disinfectants, anti-
septics, and antibiotics. Antiseptics are broad spectrum
with less risk of bacterial resistance. The difference
between antibiotics and antiseptics is that antiseptics
are nonspecific, while antibiotics work specifically on
bacteria functions or processes such as disputing cell
wall function but also can allow bacteria opportunity
to mutate and develop resistance. As a result, topical
antibiotics are not recommended for chronic wounds
because of the risk of antibiotic resistance. A variety of
modern antiseptic-impregnated dressings have been
used to reduce microorganism numbers in the dress-
ings and, in theory, on the wound surface. Their effect
on biofilm organisms is less-well defined. Table 149-4
lists these antiseptics.
Moisture imbalance involves the assessment and
management of wound exudate. While acute wound
fluid promotes cell growth and is rich in cytokines
and growth factors, chronic wound fluid inhibits cell
growth and contains high levels of proteases and
proinflammatory cytokines. Thus, acute wounds

Kang_CH149_p2700-2718.indd 2708 04/12/18 9:35 am

 Biofilm formation In Vivo 22
(Porcine)

SEM

Wound bed Staphylococcus aureus

72 hours

Chapter 149 :: Wound Healing

Figure 149-5 Biofilm formation. Colonies of microorganisms with a surrounding glycocalyx. SEM, scanning electron micrograph.

benefit from contact with wound fluid, whereas
chronic wounds do not. Moisture can hinder wound
healing in other ways as well: extra moisture can dam-
age periwound skin, and lack of moisture can hinder
keratinocyte migration.
The major dressing types (Table 149-5) include
hydrogels, transparent polyurethane films, hydrocol-
loids, gelling fibers, alginates, foams, superabsorbents,
and collagen products. In determining the most appro-
priate dressing for a particular wound, one must con-
sider the need for absorption of exudate (foams and
alginates), the need for additional moisture (hydro-
gels), and whether the wound and its epithelial edges
can tolerate the often subtle (but important) trauma
that comes from removal of adhesive dressings such as
films. Thin contact layers, consisting of different poly-
meric materials, some with perforations, allow wound
fluid to escape and are useful in preventing tissue
injury upon dressing changes.
Edge assessment involves the assessment of non-
advancing wound edges and proper use of therapies
to advance the wound edge.21 Keratinocytes from the
edge of chronic wounds often abnormally express
c-myc and treatments, such as debridement, which
remove or reverse this cellular biomarker, can promote
keratinocyte migration.78-80

TABLE 149-4
Common Antiseptics Used in Wound Healing109,110,125,126
ANTISEPTICS MAIN ADVANTAGES MAIN DISADVANTAGES

Iodine Based:
Povidine-iodine 10%
■ Cadexomer iodine
■ Inadine
Chlorhexidine Based:
■ PHMB (polyhexamethylene
biguanide)—foam, gauze
Silver-Based:
■ Microcrystalline silver
■ Silver sulfadiazine cream
■ Silver nitrate sticks
Honey-Based:
■ Broad spectrum ■ Toxic to granulation tissue in high concentration
■ Good penetration to biofilm ■ Risk of thyroid dysfunction
■ Proinflammatory ■ Risk of contact dermatitis
■ Broad spectrum ■ May damage cartilage/ear toxicity
■ 0.02% concentration use for
wound irrigation
Antiinflammatory, antibacterial, Silver toxicity, argyria with silver sulfasalazine; silver sulfadiazine +
antifungal, antiviral silver nitrate sticks may produce pseudoeschar/delay healing

■ Honey alginate Antiinflammatory, best for hard Risk of botulism; may promote bacterial growth
■ Honey gel adherent eschar
2709

Kang_CH149_p2700-2718.indd 2709 04/12/18 9:35 am

22 TABLE 149-5
Main Categories of Dressings109,110,125,126
DRESSING CATEGORY INGREDIENTS FUNCTION COMMENTS
Hydrogels ■ Polymers with high water content ■ Provide moisture ■ Needs secondary dressings
■ Nonpainful ■ Contraindicated in infected wounds
■ Needs frequent dressing change
Films ■ Semipermeable adhesive sheets of elastic ■ Transparent ■ Adherent (trauma when removed)
polyurethane ■ Nonabsorbent
■ Impermeable to water and bacteria
Hydrocolloids ■ Hydrophilic colloid particles bound to ■ Long wear time ■ Nonabsorptive
polyurethane film ■ Autolytic debridement ■ Trauma with removal
■ Some composed of gelatin, pectin, and ■ Allergy to adhesives
carboxy methylcellulose ■ Smell
Part 22

Calcium alginates ■ Sheets (wick laterally) ■ Hemostatic ■ Need secondary dressing

■ Ropes (wick upward) ■ Absorptive
■ From seaweed-kelp ■ Autolytic debridement
::

Gelling fibers ■ Sheets or ribbons ■ Absorptive ■ Needs secondary dressing

■ Autolytic debridement
Vascular Diseases

Foams ■ Polyurethane foam fluid exchange with ■ Absorbent ■ Bulky and may macerate surround-
partial fluid retention if variable pore size ing skin
Superabsorbent ■ Fiber technology/conducts moisture ■ Absorbent ■ Bulky
dressings ■ Diaper technology
Collagen-based ■ Bovine-derived collagen dressings ■ Promote healing ■ Cost
dressings ■ Reduce matrix
metalloproteinases

example “prewounding” of the donor site skin prior

SKIN GRAFTS
Skin grafts are categorized by the amount of tissue
being grafting. For example, split-thickness grafts
include a portion of dermis and full-thickness grafts
contain the entire dermis. The likelihood of the survival
and whether wound contracture is reduced depends on
the amount of dermis in the graft. Split-thickness skin
grafts can survive in areas with less vascularity but also
are less likely to prevent wound contracture, whereas
full-thickness skin grafts require better vascularity for
survival and but can better prevent contracture.
While skin grafting is centuries old, modern grafting is
thought to have begun with the first skin autotransplant
done in 1869 by Reverdin and then in 1929 by Brown and
colleagues who introduced the technique of the split-
thickness skin graft.81 The healing of a skin graft, how-
ever, is different from the description provided earlier of
the events after acute injury. One distinguishing feature
of skin graft “take” or healing is the dependence of the
graft on the recipient wound bed for revascularization,
which requires several unique physiologic events.
Much of the remainder of skin graft healing involves
events in common with the normal wound healing
process. Infiltration by fibroblasts in the graft occurs
3 to 5 days after grafting, followed by a progressive
increase in both graft and recipient fibroblasts within
the graft.82,83 Although graft “take” allows for donor
tissue to replace missing tissue in the recipient wound,
2710 skin grafts may also stimulate wound healing of the
recipient site, and this ability can be augmented. For
to grafting enhances the graft’s ability to stimulate
healing.83,84 Ki67 antibody and β1-integrin expression
after grafting has been noted, as has production of
stimulatory growth factors and cytokines, implying
that healing stimuli were provided by the grafts.85
SKIN SUBSTITUTES
Skin substitutes are divided into 2 main groups of cel-
lular and acellular matrix products (Table 149-6).86
CELLULAR PRODUCTS
The cellular skin substitute products with best avail-
able evidence are the bilayered living cellular construct
(BLCC), Apligraf (Organogenesis, Canton, MA) and
cellular dermal matrix, Dermagraft (Organogenesis,
Canton, MA). BLCC is a tissue-engineered cellular
matrix composed of bovine Type I collage with neo-
natal foreskin fibroblasts for dermal component and
human neonatal keratinocytes for epidermis.87 BLCC
has FDA approval for venous leg ulcers (VLUs) greater
than 4 weeks’ duration and for full-thickness diabetic
foot ulcers present for longer than 3 weeks. The evi-
dence supports the safety and efficacy of up to 5 appli-
cations of BLCC. An example of its efficacy is 47% of
chronic, hard-to-heal VLUs present longer than 1 year
treated with BLCC healed after 24 weeks compared to
19% in the group with compression alone.88

Kang_CH149_p2700-2718.indd 2710 04/12/18 9:35 am

 TABLE 149-6
22
Cellular and Acellular Matrices86
NAMES ADVANTAGE FDA APPROVAL

Cellular Matrices:
Bilayered living cellular construct (Apligraf,
Organogenesis, Canton, MA)
Cellular dermal matrix (Dermagraft,
Organogenesis, Canton, MA)
Dehydrated human amnion/chorion
Dermal part: Bovine Type I collagen with
human neonatal foreskin fibroblasts
Epidermal part: keratinocytes
Human neonatal foreskin fibroblasts cultured
onto a bioresorbable glycolic acid scaffold
(polyglactin 910)
DHACM is composed of a single layer of
Noninfected partial- and full-thickness venous
leg ulcers, >1 month duration
Full-thickness diabetic foot ulcers, >3 weeks’
duration
Full-thickness diabetic foot ulcers >6 weeks’
duration that do not involve tendon, muscle,
joint capsule, or bones
DHACM is composed of a single layer of

Chapter 149 :: Wound Healing

membrane (DHACM) (Epifix, MiMedx Group
Inc., Marietta, GA)
Cryopreserved placental membrane (Grafix,
Osiris Therapeutics, Inc., Columbia, MD)
Acellular Matrices:
Dermal regeneration matrix (Integra Dermal
Regeneration Template, Integra, Life Sciences,
Plainsboro, NJ)
Porcine small intestinal submucosa (Cook
Biotech, West Lafayette, Indiana)
Cadaveric allograft (AlloDerm Regenerative
Tissue Matrix [RTM], LifeCell, , Branchburg, NJ)
Poly-N-acetyl glucosamine–derived membrane
(Talymed, Marine Polymer Technologies Inc.,
Danvers, MA)
epithelial cells, a basement membrane, and
an avascular connective tissue matrix
Human viable wound matrix provides the
wound with mesenchymal stem cells,
neonatal fibroblasts, epithelial cells, growth
factors, and angiogenic factors
Composed of a crosslinked bovine tendon
collagen and glycosaminoglycan der-
mal equivalent, and a semipermeable
polysiloxane (silicone) epidermal equivalent
Derived from small intestinal submucosa of
porcine; 3-dimensional extracellular matrix
that acts as a scaffold to allow for cellular
migration, formation of granulation tissue,
and vascularization of the wound
Cadaveric human skin that has been processed
to remove the epidermis and cells that lead
to tissue rejection and graft failure
Composed of poly-N-acetyl glucosamine short-
ened fibers that are derived from microalgae
epithelial cells, a basement membrane, and
an avascular connective tissue matrix
Human viable wound matrix provides the
wound with mesenchymal stem cells,
neonatal fibroblasts, epithelial cells, growth
factors, and angiogenic factors
FDA-approved device (510[k] for diabetic foot
ulcers)
FDA-approved 510(k)-cleared medical device
Regulated by the FDA as human tissue for
transplantation
FDA approved—510(k)

Cellular dermal matrix is composed of human neo-
natal foreskin fibroblasts cultured onto a bioabsorbable
glycolic acid scaffold. The fibroblasts secrete collagen,
matrix proteins, growth factors, and cytokines. It has
FDA approval for diabetic foot ulcers of longer than
6 weeks’ duration.
Human placental products also are used to speed
healing of chronic wounds. The 2 supported by evi-
dence (albeit less robust) include dehydrated human
amnion/chorion membrane (Epifix, MiMedx, Marietta,
GA) and cryopreserved placental membrane (Grafix,
Osiris Therapeutics Inc.). Epifix is composed of a sin-
gle layer of epithelial cells, a basement membrane, and
a connective tissue matrix. Grafix is composed of pla-
cental membrane, a source of mesenchymal stem cells,
neonatal fibroblasts, epithelial cells, growth factors,
and angiogenic cells.89-92
ACELLULAR PRODUCTS
Acellular products function as a scaffold for cel-
lular migration, proliferation, and matrix forma-
tion. Examples of acellular products include dermal
regeneration matrix, porcine small intestinal sub-
mucosa, cadaveric allograft, and poly-N-acetyl
glucosamine.86
INTEGRA Dermal Regeneration Template (Integra
LifeSciences Corp.) is a bilayered acellular matrix com-
posed of crosslinked bovine tendon collagen, a glycos-
aminoglycan dermal equivalent, and a semipermeable
polysiloxane epidermal equivalent. It is approved for
burns and diabetic foot ulcers. In a recent study on
diabetic foot ulcer patients, 51% of patients on Dermal
Regeneration Template achieved complete healing,
compared to 32% of controls.93,94 Porcine small intes-
tine submucosa (Oasis, Smith, & Nephew) is a scaffold
for cellular migration, granulation tissue formation
and neovascularization. The evidence supports the
successful use of small intestine submucosa in patients
with diabetic foot ulcers and VLUs.95 Cadaveric
allograft is made of cadaveric human skin. It is indi-
cated for tissue repair in abdominal wall and breast
reconstruction.96 Poly-N-acetyl glucosamine (Talymed)
is derived from microalgae and has FDA approval for a
variety of wounds. Poly-N-acetyl glucosamine has also
2711
antibacterial properties.97

Kang_CH149_p2700-2718.indd 2711 04/12/18 9:35 am

22 STEM CELL THERAPY
The use of stem cells in the management of wounds
aims to replace the wound resident cells with new
cells with the potential to respond to wound heal-
ing process signals. Numerous animal studies and a
small number of pilot studies in human have shown
that bone marrow mesenchymal cells can promote
wound healing.98,99 In 2003, freshly applied autologous
bone marrow aspirate and cultured bone marrow cells
helped 3 wounds heal.100,101 In animal models, the use
of stem cells is associated with healing and increase in
tensile strength. In addition to bone marrow–derived
Part 22
cells, other sources of stem cells, such as fat and hair
follicles, may be beneficial.98
However, most studies of adult stem cell therapy
for human wounds have used cultured bone marrow–
::
derived mesenchymal stem cells.102 The improvement of
Vascular Diseases
wounds with adult stem cells may be a result of either
integration of the stem cells or their paracrine effects.103
Topically applied autologous mesenchymal stem cells
accelerate the healing of human and murine wounds.104
The first randomized, controlled trial reported the use
of bone marrow mesenchymal stem cell application via
IM and subcutaneous injection to chronic nonhealing
wounds with success compared to standard care.105
CHRONIC WOUNDS AND
IMPAIRED HEALING
Acute wounds, such as those created by surgery or
by trauma, have a predictable time-frame for healing
and generally heal quite readily when not interrupted.
Impaired healing in chronic wounds may be a conse-
quence of many factors.
Some chronic wounds are the result of ischemia,
pressure, and infection or a combination, thereof.26
There is still considerable controversy whether hyper-
glycemia itself plays a pathophysiologic role in the
development of ulcers in patients with diabetes mel-
litus, although neutrophil function is impaired in this
setting, and the propensity to infection is enhanced in
the diabetic state.26 Importantly, the notion of “small
vessel disease” in diabetes mellitus has not been
shown to be an obstructive phenomenon. Revascular-
ization of the diabetic foot is now viewed as standard
care in the presence of large vessel disease and good
run-off circulation.
Perhaps the best example of truly impaired healing,
not related to undue pressure and poor arterial sup-
ply, is venous ulceration. The underlying abnormality
in the development of venous ulcers is the presence of
sustained ambulatory venous pressure, also known
as venous hypertension, which refers to the inability
of venous pressure in the leg and feet to decrease in
response to exercise.106 It should also be recognized
2712 that the tissue surrounding chronic wounds is not nor-
mal and has been altered by the primary pathogenic
Kang_CH149_p2700-2718.indd 2712
mechanisms or inability to heal readily. Clinically, the
best example of this is the intense fibrosis surround-
ing venous ulcers, as seen in lipodermatosclerosis.107,108
Lipodermatosclerosis is a risk factor for ulceration, and
venous ulcers surrounded by lipodermatosclerosis are
more difficult to heal.109,110
Evidence suggests an alteration of the cellular
makeup of wounds that do not heal. Fibroblasts
derived from venous ulcers are unresponsive to cer-
tain selected cytokines and growth factors.111 For exam-
ple, venous ulcer fibroblasts are unresponsive to the
action of TGF-β1 and PDGF.111,112 The lack of response
to stimuli such as TGF-β1 may be because of decreased
expression of Type II TGF-β receptors. This receptor
abnormality also leads to decreased phosphorylation
of key TGF-β signaling proteins, including Smad2,
Smad3, and mitogen-activated protein kinases.113 Cells
in diabetic ulcers are altered, such that chronic wounds
are said to be “stuck” in a certain phases of the repair
process.114 An association has been reported between
some of these cellular alterations and the inability to
heal.115,116
AGE-RELATED CHANGES IN
WOUND HEALING
The population is aging, and older adults are more
prone to develop all type of wounds, including VLUs,
arterial ulcers, and pressure ulcers. For both acute
and chronic wounds, aging is associated with delayed
healing. The healing response by ECM changes
throughout life.117 Overexpression of MMPs has been
shown in elderly skin.117 The vasoregulation in aged
skin includes fewer progenitor cells, impaired per-
fusion and changes in temperature regulation. Age-
associated aberrations in macrophage function delay
vascularization, collagen formation, and remodeling.
Mitochondrial dysfunction and lower levels of anti-
oxidants also are associated with aging. Comorbidities
and polypharmacy may also factor into delayed heal-
ing in the elderly population.118-120
BASIC STANDARDS OF
WOUND CARE
Reversing or treating the underlying cause of impaired
healing is the focus of wound care treatment. Treat-
ment relies in part on wound etiology. A thorough
history and examination, along with adjunctive diag-
nostic tests, such as wound biopsy, vascular studies,
imaging, tissue culture, and laboratory analysis may
help with diagnosis.121,122 The most common lower
extremity ulcers are venous, diabetic, and arterial
ulcers. Chronic wounds are common. VLUs have a 2%
prevalence in developed countries, and diabetic foot
ulcers occur in 1 in 4 patients with diabetes mellitus
over their lifetime.17,123,124
04/12/18 9:35 am
 Using VLUs as an example, the fundamental of
treatment is compression therapy with adjunctive
medical and surgical therapies.109,110,125,126 With regard
to medical therapy, pentoxifylline has been tested in
several large randomized trials for its ability to acceler-
ate the healing of venous ulcers. The results have var-
ied, and it may be that a high dose of pentoxifylline,
800 mg 3 times a day, is more effective than 400 mg
3 times a day.127 Whether the use of pentoxifylline
should be considered standard therapy for venous
ulcers is unclear at the moment. The anabolic steroid
stanozolol has been effective in diminishing the indu-
ration of lipodermatosclerosis, and in the acute and
painful phase of lipodermatosclerosis, when compres-
sion bandages and stockings are too painful to use.128
Danazol may be a useful substitute for stanozolol if
it is not available. Recent studies show an effect of
statins in the healing of VLUs (and possibly diabetic
foot ulcers).129,130 The only known medical approach
for decreasing recurrence of venous ulcers seems to be
graded elastic stockings, with a pressure at the ankle
in the range of 40 mm Hg along. Surgical therapy is an
adjunct, if indicated. Stockings should be considered a
lifelong therapy to help prevent ulcer recurrence and
the other manifestations of venous disease.
PREDICTING WOUND
CLOSURE
Several recent studies now allow the prediction of
whether a wound will heal in a timely fashion from
simple observation in the first 3 to 4 weeks of therapy.
The methods used to predict wound closure range
from simple measurements of wound size (width and
length) and change in wound area, to computerized
planimetric analysis and assessment of migration of
the wound edge.131 In a study of 56,488 wounds, it was
shown that a percent change of approximately 30% at
4 weeks could predict wound closure with a sensitivity
of 0.67, a specificity of 0.69, and had a positive and neg-
ative predictive value of 0.80 and 0.52, respectively.132
In practical terms, the appearance of the wound
edge is important. Steep edges imply no progress
of the wound, while the edges of healing wounds
become less steep and begin to migrate toward the
center. The implications of the ability to predict
closure are very important. By 4 weeks, the clinician
should be able to determine whether the current
therapy should be continued or whether a change
is required, including a complete reassessment of the
clinical situation. The prognostic value of the healing
rate by 4 weeks of therapy has been confirmed.132,133
CONCLUSIONS
Wound healing is a complex process of overlapping
phases of inflammation, proliferation and remodel-
ing. The burden of wounds on millions of people is
globally underappreciated. There are still challenges,
Kang_CH149_p2700-2718.indd 2713
in terms of improving the fundamentals of care in
limited-resource countries, as well as research gaps in
22
smart biologic dressings, bioengineered skin, and stem
cell therapy. We need continued and increased under-
standing of the science involved. It is also possible
that lessons learned from failure to heal, as in chronic
wounds, will provide valuable lessons for the general
principles of surgical and acute wound healing.
REFERENCES
1. Enoch S, Leaper DJ. Basic science of wound healing.
Surgery (Oxford). 2008;26:31-37.
Chapter 149 :: Wound Healing
2. Li J, Chen J, Kirsner R. Pathophysiology of acute
wound healing. Clin Dermatol. 2007;25:9-18.
3. Kirsner RS, Eaglstein WH. The wound healing process.
Dermatol Clin. 1993;11:629-640.
4. Nosbaum A, Prevel N, Truong HA, et al. Cutting edge:
regulatory T cells facilitate cutaneous wound healing.
J Immunol. 2016;196(5):2010-2014.
5. Vatankhah N, Jahangiri Y, Landry GJ, et al. Predictive
value of neutrophil-to-lymphocyte ratio in diabetic
wound healing. J Vasc Surg. 2017;65(2):478-483.
6. Xue M, Le NT, Jackson CJ. Targeting matrix metal-
loproteases to improve cutaneous wound healing.
Expert Opin Ther Targets. 2006;10:143-155.
7. Werner S, Grose R. Regulation of wound healing by
growth factors and cytokines. Physiol Rev. 2003;83:
835-870.
8. Patel S, Maheshwari A, Chandra A. Biomarkers for
wound healing and their evaluation. J Wound Care.
2016;25:46-55.
9. Golebiewska EM, Poole AW. Platelet secretion: From
haemostasis to wound healing and beyond. Blood
Rev. 2015;29:153-162.
10. Leaper D. Perfusion, oxygenation and warming. Int
Wound J. 2007;4(suppl 3):4-8.
11. Ramasastry SS. Acute wounds. Clin Plast Surg. 2005;
32:195-208.
12. Rothwell SW, Sawyer E, Dorsey J, et al. Wound heal-
ing and the immune response in swine treated
with a hemostatic bandage composed of salmon
thrombin and fibrinogen. J Mater Sci Mater Med.
2009;20:2155-2166.
13. Frechette JP, Martineau I, Gagnon G. Platelet-rich
plasmas: growth factor content and roles in wound
healing. J Dent Res. 2005;84:434-439.
14. Martin P, Leibovich SJ. Inflammatory cells during
wound repair: the good, the bad and the ugly. Trends
Cell Biol. 2005;15:599-607.
15. Baum CL, Arpey CJ. Normal cutaneous wound heal-
ing: clinical correlation with cellular and molecular
events. Dermatol Surg. 2005;31:674-686; discussion
686.
16. Pull SL, Doherty JM, Mills JC, et al. Activated mac-
rophages are an adaptive element of the colonic
epithelial progenitor niche necessary for regen-
erative responses to injury. Proc Natl Acad Sci U S A.
2005;102:99-104.
17. Snyder RJ, Lantis J, Kirsner RS, et al. Macrophages: a
review of their role in wound healing and their thera-
peutic use. Wound Repair Regen. 2016;24:613-629.
18. Pradhan L, Cai X, Wu S, et al. Gene expression of
pro-inflammatory cytokines and neuropeptides in 2713
diabetic wound healing. J Surg Res. 2011;167:336-342.
04/12/18 9:35 am