Wound healing: cellular mechanisms

and pathological outcomes

Holly N. Wilkinson and Matthew J.
Hardman
http://dx.doi.org/10.1098/rsob.200223
Dr. Md Shaklin
Date- 29/07/2024
Journal club

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 Introduction
• Millennia of evolution have created our skin, a highly
adaptive, multifunctional organ that protects us from a
daily onslaught of chemical, physical and ultraviolet
radiation challenge.
• This harsh external environment often results in injury to
the skin, and it will therefore come as no surprise that our
skin possesses sophisticated reparative processes that
allow it to heal quickly and efficiently.
• Despite considerable innate reparative ability, multiple
cellular aspects of an individual’s injury response can
become attenuated, compromising wound closure.
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 Cellular aspects of acute wound repair
• Our skin is specialized to interface with the external
environment and provides a variety of important
homeostatic functions, from regulating thermostability to
sensing extrinsic stimuli.
• Crucially, the skin acts as a primary defence barrier,
preventing desiccation and mechanical, chemical, thermal
and photic damage to internal structures.
• This defence extends to a sophisticated immune barrier
response that protects against pathogenic infection, while
supporting commensal microorganisms via an elegantly
adapted host–microbiota axis
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 Haemostasis
• Immediately after injury, damaged blood vessels rapid contract
and a blood clot forms preventing exsanguination from vascular
damage.
• Platelets, principle contributors to haemostasis and coagulation,
are activated when they encounter the vascular subendothelial
matrix.
• Platelet receptors (e.g. glycoprotein VI) interact with
extracellular matrix (ECM) proteins (e.g. fibronectin, collagen and
von Willebrand factor), promoting adherence to the blood vessel
wall.
• Thrombin subsequently triggers platelet activation, inducing a
conformational change, and release of alpha and dense granules
containing bioactive molecules which reinforce coagulation.
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 Inflammation
• Innate inflammation evolved as the primary defence against
pathogenic wound invasion.
• This immune response is initiated by injury-induced signals; damage-
associated molecular patterns (DAMPs) released by necrotic cells
and damaged tissue, and pathogen-associated molecular patterns
(PAMPs) from bacterial components.
• Pro-inflammatory molecules also stimulate vasodilatation, which,
along with the expression of endothelial cell adhesion molecules,
such as selectins, facilitates neutrophil and monocyte adhesion and
diapedesis.
• The inflammatory response is complex, modulated by a multitude
host of intrinsic and extrinsic factors. Uncontrolled and excessive
inflammation promotes tissue injury and delays healing.
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• Circulating monocytes enter the wound tissue where, in
response to the local milieu, they differentiate into
macrophages.
• Although it is generally suggested that macrophages are
recruited following neutrophils, an initial wave of monocytes
has been observed entering the wound simultaneously with
neutrophils.
• Wound macrophages are traditionally separated into two
main subsets: M1-stimulated and M2-stimulated.
• Classically activated macrophages are induced by
proinflammatory stimuli, such as LPS and interferon-gamma
(IFN-γ), and promote inflammation by releasing ROS,
inflammatory cytokines (e.g. IL-1, IL-6 and TNF-α) and
growth factors (e.g. vascular endothelial growth factor, VEGF
and PDGF).
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• The overwhelming presence of neutrophils
and macrophages in wounds has potentially
masked the importance of other myeloid
cells in wound repair.
• Moreover, the removal of anti-
inflammatory regulatory T cells delays
tissue repair in mice.
• Mast cells also play a role in wounds,
releasing histamine to aid neutrophil
recruitment during early inflammation.
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 Proliferation
• The proliferative phase of healing is characterized by extensive activation of
keratinocytes, fibroblasts, macrophages and endothelial cells to orchestrate wound
closure, matrix deposition and angiogenesis.
• Hair follicle stem cells are induced to proliferate, with progeny epidermal cells
streaming out of the follicle to meet the cellular demand required to resurface the
wound.
• Keratinocytes negotiate through debris and necrotic tissue of the wound bed
through their interactions with structural proteins of the preliminary matrix via
integrin receptors.
• Macrophages play a significant role in angiogenesis by aiding microvascular
endothelial cell behaviours. They produce proteases such as MMPs to degrade the
dense fibrin network and chemotactic factors (e.g. TNF-α, VEGF and TGF-β) to drive
endothelial migration.
• The skin houses a dense network of sensory and autonomous nerve fibres which
allow sensation and movement. Nerve fibre regeneration is therefore essential
following injury.
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 Matrix remodelling
• Remodelling of the ECM spans the entire injury response,
beginning with the initial deposition of a fibrin clot, and ending
several years later with the formation of a mature, type I
collagen-rich scar.
• These sequential changes in the ECM require a fine balance
between collagen degradation and synthesis, achieved through
temporal regulation of key MMPs.
• Heightened expression of TGF-β and mechanical tension
stimulate myofibroblast differentiation in vivo and in vitro.
• Myofibroblasts are characterized by an abundance of alpha-
smooth muscle actin (α-SMA), associated with an ability to
gene.
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 When healing fails—factors influencing
chronic wound healing
• Acute wound repair is a highly dynamic cascade of cellular signalling and
behavioural events that ensures rapid closure of the skin barrier.
• They primarily affect the elderly and diabetic, are highly prevalent and a
major socioeconomic burden.
• More effective clinical management would prevent a proportion of these
wounds, yet many remain refractory to current treatment, highlighting the
need to better understand the cellular basis of wound pathology in order
to develop therapeutically viable treatments.
• Susceptibility to injury remains understudied. We know that the skin of
aged and diabetic mammals is more predisposed to injury, as it undergoes
atrophy, with altered skin barrier and reduced hydration.
• A key contributor to wound pathology is excessive inflammation, which
perpetuates chronicity through the continued destruction of wound
tissue.

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• Cellular impairment is not only restricted to inflammation, but also
extends to re-epithelialization and dermal remodelling.
• Non-healing diabetic foot ulcers are typically characterized by an
epidermal wound edge that is hyperkeratotic and parakeratotic.
• At the same time, dermal reconstitution is significantly inhibited by the
high wound protease levels, which not only break down dermal ecm
components, but also degrade growth factors (e.G. VEGF and tgf-β) and
cytokines (e.G. Tnf-α).
• Sustained hyperglycaemia in diabetes directly contributes to defective
healing, compromising leucocyte function, inducing cellular senescence
and causing non-enzymatic glycation of ecm and the formation of
advanced glycation end products.
• It is crucial to note that the causes of delayed healing, while simplified
above, are often multifactorial and complex.
• The microbiome profiles of aged and diabetic skin differ considerably from
their young and non-diabetic counterparts, in each case displaying
reduced α-diversity.

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 Translational techniques to enhance clinical
understanding of wounds
• Our knowledge of the mechanisms underlying chronic wound healing is
constantly improving, largely due to the development and refinement of
wound models and diagnostic tools Our knowledge of the mechanisms
underlying chronic wound healing is constantly improving, largely due to
the development and refinement of wound models and diagnostic tools.
• Porcine and human ex vivo models are also gaining traction, with the
advantage that they provide native skin tissue architecture and the full
gamut of resident skin cells to recapitulate important aspects of the human
chronic wound healing response.
• In vivo models are still widely used, with mice favoured for mechanistic
studies.
• The multitude of available transgenic mouse lines (including reporter lines)
allows temporal and spatial investigation of the molecular basis of in vivo
wound healing.

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Current therapies and future opportunities

• Wound management begins with an assessment of wound

aetiology and a patient-centric approach to managing
systemic and lifestyle factors. In the case of diabetic foot
ulcers, local management often starts with debridement,
the removal of necrotic, infected or hyperkeratotic tissue
via surgical or less invasive modalities.
• Contemporary dressings contain a myriad of material
properties to aid tissue repair and incorporate substances
with known pro-healing or antimicrobial effects.
• A major contributor to chronic wound recalcitrance is
persistent, antibiotic-resistant biofilm infection.
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• It is therefore unsurprising that a large proportion of recent wound
research has focused on the development of novel antimicrobial
and anti-biofilm therapies.
• Most antimicrobials display broad effects and are not targeted to
specific pathogenic species and strains.
• This is important, as commensal bacteria have a positive role in skin
maintenance and wound repair, and unlike their pathogenic
counterparts, commensal biofilms do not cause persistent delayed
healing in diabetic wounds.
• Experimental studies are providing new insight into the underlying
molecular and cellular correlates to chronic wound pathology.
• This in turn offers exciting new avenues for future therapeutic
prevention and intervention.
• Repurposing these existing treatments offers an attractive approach
for wound management. Other cell-targeted strategies include the
administration of stem cells, growth factors and gene therapies.
• The major reparative effects of emerging and potential chronic
wound therapies are outlined in figure 3
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 Conclusion
• The high cellular diversity, complexity and plasticity of wound healing
provide a considerable challenge to comprehensively elucidate.
• While this remains a perplexing goal, it is essential that we continue to
strive to more fully understand the mechanisms that underpin both
normal and pathological healing.
• While not without their limitations, emerging wound models provide
an unprecedented opportunity to further explore the molecular and
cellular features of wound repair.
• Combining these approaches with novel tissue, cell and molecular
‘omics’ technologies will considerably advance our understanding of
wound pathology.
• Indeed, the future holds great promise for the development of
innovative new therapeutic strategies for advanced wound care.

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 Critical analysis
• Pros
• Comprehensive Review: The article systematically reviews multiple studies on
the effectiveness of autologous platelet concentrates for alveolar socket
preservation, offering a thorough analysis of existing research​
(moraschini2015 Effect o…)​.
• Diverse Study Designs: The inclusion of different study designs, such as
randomized controlled trials (RCTs) and controlled clinical trials (CCTs),
provides a well-rounded perspective on the topic​(moraschini2015 Effect o…)​.
• Detailed Methodology: The authors follow a rigorous methodology, including
a PRISMA-based approach and a systematic search strategy, ensuring that the
review is structured and reliable​(moraschini2015 Effect o…)​.
• Positive Findings: The article highlights the potential benefits of autologous
platelet concentrates, such as accelerated healing of soft and hard tissues,
reduced inflammation, and less pain and discomfort​(moraschini2015 Effect
o…)​.
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• Cons
• Heterogeneity of Studies: The reviewed studies exhibited
significant heterogeneity in design, which limited the ability to
conduct a meta-analysis and led to a descriptive analysis
instead​​.
• Bias and Quality Concerns: Not all included studies had a low
risk of bias. Some had moderate or high risks, which could
affect the validity of the findings​.
• Limited Comparisons: The article points out that there were no
significant differences found between different types of plasma
concentrates (PRP vs. PRF), and a direct comparison study was
not available, limiting the strength of conclusions about the
superiority of one method over the other​​.
• Variability in Outcomes: The outcomes measured in the
included studies varied, making it difficult to standardize the
results and draw uniform conclusions​​.
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