TGF-beta: a fibrotic factor in wound scarring and a potential target for anti-scarring gene therapy

Hypertrophic scar and keloid are common and difficult to treat diseases in plastic surgery. Results of wound healing research over the past decades have demonstrated that transforming growth factor-beta (TGF-beta) plays an essential role in cutaneous scar formation. In contrast, fetal wounds, which heal without scarring, contain a lower level of TGF-beta than adult wounds. How to translate the discovery of basic scientific research into the clinical treatment of wound scarring has become an important issue to both clinicians and basic researchers. The development of gene therapy techniques offers the potential to genetically modify adult wound healing to a healing process similar to fetal wounds, and thus reduces wound scarring. This article intends to review the roles of TGF-beta in the formation of wound scarring, the possible strategies of antagonizing wound TGF-beta, and our preliminary results of scar gene therapy, which show that wound scarring can be significantly reduced by targeting wound TGF-beta.     

Tissue Engineering and Regenerative Repair in Wound Healing

Wound healing is a highly evolved defense mechanism against infection and further injury. It is a complex process involving multiple cell types and biological pathways. Mammalian adult cutaneous wound healing is mediated by a fibroproliferative response leading to scar formation. In contrast, early to mid-gestational fetal cutaneous wound healing is more akin to regeneration and occurs without scar formation. This early observation has led to extensive research seeking to unlock the mechanism underlying fetal scarless regenerative repair. Building upon recent advances in biomaterials and stem cell applications, tissue engineering approaches are working towards a recapitulation of this phenomenon. In this review, we describe the elements that distinguish fetal scarless and adult scarring wound healing, and discuss current trends in tissue engineering aimed at achieving scarless tissue regeneration.     

The impact of cyclooxygenase-2 mediated inflammation on scarless fetal wound healing

Cyclooxygenase-2 (COX-2) and the prostaglandin products generated as a result of COX-2 activity mediate a variety of biological and pathological processes. Scarless healing occurs in fetal skin in the first and second trimesters of development. This scarless healing process is known to proceed without a significant inflammatory response, which appears to be important for the lack of scarring. Because the COX-2 pathway is an integral component of inflammation, we investigated its role in the fetal repair process using a mouse model of scarless fetal wound healing. COX-2 expression in scarless and fibrotic fetal wounds was examined. In addition, the ability of exogenous prostaglandin E(2) to alter scarless fetal healing was evaluated. The results suggest that the COX-2 pathway is involved in scar production in fetal skin and that targeting COX-2 may be useful for limiting scar formation in adult skin.     

Differential expression of fibromodulin, a transforming growth factor-beta modulator, in fetal skin development and scarless repair

Transforming growth factor-beta (TGF-beta1, -beta2, and -beta3) has been implicated in the ontogenetic transition from scarless fetal repair to adult repair with scar. Generally, TGF-beta exerts its effects through type I and II receptors; however, TGF-beta modulators such as latent TGF-beta binding protein-1 (LTBP-1), decorin, biglycan, and fibromodulin can bind and potentially inhibit TGF-beta activity. To more fully explore the role of TGF-beta ligands, receptors, and potential modulators during skin development and wound healing, we have used a rat model that transitions from scarless fetal-type repair to adult-type repair with scar between days 16 and 18 of gestation. We showed that TGF-beta ligand and receptor mRNA levels did not increase during the transition to adult-type repair in fetal skin, whereas LTBP-1 and fibromodulin expression decreased. In addition, TGF-beta1 and -beta3; type I, II, and III receptors; as well as LTBP-1, decorin, and biglycan were up-regulated during adult wound healing. In marked contrast, fibromodulin expression was initially down-regulated in adult repair. Immunostaining demonstrated significant fibromodulin induction 36 hours after injury in gestation day 16, but not day 19, fetal wounds. This inverse relationship between fibromodulin expression and scarring in both fetal and adult rat wound repair suggests that fibromodulin may be a biologically relevant modulator of TGF-beta activity during scar formation.     

Comparison of bone morphogenetic protein receptors expression in the fetal and adult skin.

Wounds on fetal skin can be repaired without leaving scars until the second trimester, but after this period, skin wounds leave scars as in adults. It's known that certain growth factors such as TGF-beta, and bFGF are present at a very low levels during wound repair in fetal skin. These low levels of growth factors minimize inflammatory response and fibroblast proliferation at the wound site, which in turn inhibit collagen synthesis, and thus, allows scarless wound healing. Recently bone morphogenetic proteins (BMPs), one of the TGF-beta superfamily members, have been studied in the wound healing process. According to several studies, BMPs are related to the differentiation and growth of epithelial and mesenchymal cells, but the precise functions of BMPs and of BMP receptors on skin wound healing have not been elucidated. In this study, we investigated the expression pattern of BMP receptors in fetal skin during the second trimester and in adult skin by immunohistochemical staining and RT-PCR. BMP receptors were detected on the suprabasal epithelial cells and in the hair follicles in adult skin, but were not defected in the fetal skin except for the hair follicles. This was confirmed by confirming mRNA levels of BMP receptors by RT-PCR in both adult and fetal skins. In conclusion, BMPs and BMP receptors seem to be related to fetal and adult wound healing, and low levels of BMPs and BMP receptors during the second trimester seem to contribute to scarless wound healing in the fetus, as is TGF-beta during the second trimester.     

Location of injury influences the mechanisms of both regeneration and repair within the MRL/MpJ mouse

The adult MRL/MpJ mouse regenerates all differentiated structures after through-and-through ear punch wounding in a scar-free process. We investigated whether this regenerative capacity was also shown by skin wounds. Dorsal skin wounds were created, harvested and archived from the same animals (MRL/MpJ and C57BL/6 mice) that received through-and-through ear punch wounds. Re-epithelialization was complete in dorsal wounds in both strains by day 5 and extensive granulation tissue was present by day 14 post-wounding. By day 21, wounds from both strains contained dense amounts of collagen that healed with a scar. The average wound area, as well as alpha-smooth muscle actin expression and macrophage influx were investigated during dorsal skin wound healing and did not significantly differ between strains. Thus, MRL/MpJ mice regenerate ear wounds in a scar-free manner, but heal dorsal skin wounds by simple repair with scar formation. A significant conclusion can be drawn from these data; mechanisms of regeneration and repair can occur within the same animal, potentially utilizing similar molecules and signalling pathways that subtly diverge dependent upon the microenvironment of the injury.     

Characterizing regeneration in the vertebrate ear

We have previously shown that MRL/MpJ mice have a capacity for regeneration instead of scar formation following an ear punch wound. Understanding the differences that occur between scar-free regeneration or repair with scarring will have great impact upon advances in skin tissue engineering. A key question that remains unanswered in the MRL/MpJ mouse model is whether regeneration was restricted to the ear or whether it extended to the skin. A histological analysis was conducted up to 4 months post-wounding, not only with 2-mm punch wounds to the ear but also to the skin on the backs of the same animals. MRL/MpJ mouse ear wounds regenerate faster than control strains, with enhanced blastema formation, a markedly thickened tip epithelium and reduced scarring. Interestingly, in the excisional back wounds, none of these regenerative features was observed and both the C57BL/6 control and MRL/MpJ mice healed with scarring. This review gives an insight into how this regenerative capacity may be due to evolutionary processes as well as ear anatomy. The ear is thin and surrounded on both sides by epithelia, and the dorsal skin is devoid of cartilage and under greater tensile strain. Analysis of apoptosis during ear regeneration is also discussed, assessing the role and expression of various members of the Bcl-2 family of proteins. Ongoing studies are focusing on de novo cartilage development in the regenerating ear, as well as understanding the role of downstream signalling cascades in the process. Identification of such signals could lead to their manipulation and use in a novel tissue-engineered skin substitute with scar-free integration.     

Interference with transforming growth factor-beta/ Smad3 signaling results in accelerated healing of wounds in previously irradiated skin

Transforming growth factor (TGF)-beta regulates many aspects of wound repair including inflammation, chemotaxis, and deposition of extracellular matrix. We previously showed that epithelialization of incisional wounds is accelerated in mice null for Smad3, a key cytoplasmic mediator of TGF-beta signaling. Here, we investigated the effects of loss of Smad3 on healing of wounds in skin previously exposed to ionizing radiation, in which scarring fibrosis complicates healing. Cutaneous wounds made in Smad3-null mice 6 weeks after irradiation showed decreased wound widths, enhanced epithelialization, and reduced numbers of neutrophils and myofibroblasts compared to wounds in irradiated wild-type littermates. Differences in breaking strength of wild-type and Smad3-null wounds were not significant. As shown previously for neutrophils, chemotaxis of primary dermal fibroblasts to TGF-beta required Smad3, but differentiation of fibroblasts to myofibroblasts by TGF-beta was independent of Smad3. Previous irradiation-enhanced induction of connective tissue growth factor mRNA in wild-type, but not Smad3-null fibroblasts, suggested that this may contribute to the heightened scarring in irradiated wild-type skin as demonstrated by Picrosirius red staining. Overall, the data suggest that attenuation of Smad3 signaling might improve the healing of wounds in previously irradiated skin commensurate with an inhibition of fibrosis.     

Second-harmonic generation microscopy for assessment of mesenchymal stem cell-seeded acellular dermal matrix in wound-healing

Direct intra-skin injection of mesenchymal stem cells (MSCs) and the use of biomaterial scaffolds for grafts are both promising approaches of skin wound repair, however they still cannot generate skin that completely resembles the natural skin structures. In this study, we combined these two approaches by using acellular dermal matrix (ADM) recellularized with MSCs to repair cutaneous wounds in a murine model and two-photon fluorescence (TPF) microscopy and second-harmonic generation (SHG) microscopy to assess the effects of this therapy on wound healing. Bone marrow-derived mesenchymal stem cells (BM-MSCs) were tagged with GFP and seeded into ADM (ADM-MSC) via MSC and ADM co-culture. ADM-MSC, ADM or saline was applied to murine excisional skin wounds and wound-healing was evaluated by histological examination on days 7, 14, 21 and TFP microscopy on days 1, 3, 5 and 21 post-treatment. ADM-MSC promoted healing significantly more than treatment with ADM or saline alone, as it led to substantial neovascularization and complete skin appendage regeneration. Furthermore, the SHG microscopic imaging technique proved to be a useful tool for monitoring changes in the collagen network at the wound site during the healing process and assessing the effects of different therapies.     

The interplay between extracellular matrix and progenitor/stem cells during wound healing: Opportunities and future directions

Skin wound healing, a dynamic physiological process, progresses through coordinated overlapping phases to restore skin integrity. In some pathological conditions such as diabetes, wounds become chronic and hard-to-heal resulting in substantial morbidity and healthcare costs. Despite much advancement in understanding mechanisms of wound healing, chronic and intractable wounds are still a considerable challenge to nations’ health care systems. Extracellular matrix (ECM) components play pivotal roles in all phases of wound healing. Therefore, a better understanding of their roles during wound healing can help improve wound care approaches. The ECM provides a 3D structure and forms the stem cell niche to support stem cell adhesion and survival and to regulate stem cell behavior and fate. Also, this dynamic structure reserves growth factors, regulates their bioavailability and provides biological signals. In various diseases, the composition and stiffness of the ECM is altered, which as a result, disrupts bidirectional cell-ECM interactions and tissue regeneration. Hence, due to the impact of ECM changes on stem cell fate during wound healing and the possibility of exploring new strategies to treat chronic wounds through manipulation of these interactions, in this review, we will discuss the importance/impact of ECM in the regulation of stem cell function and behavior to find ideal wound repair and regeneration strategies. We will also shed light on the necessity of using ECM in future wound therapy and highlight the potential roles of various biomimetic and ECM-based scaffolds as functional ECM preparations to mimic the native stem cell niche.     

Scar‐free cutaneous wound healing in the leopard gecko,Eublepharis macularius

Cutaneous wounds heal with two possible outcomes: scarification or near‐perfect integumentary restoration. Whereas scar formation has been intensively investigated, less is known about the tissue‐level events characterising wounds that spontaneously heal scar‐free, particularly in non‐foetal amniotes. Here, a spatiotemporal investigation of scar‐free cutaneous wound healing following full‐thickness excisional biopsies to the tail and body of leopard geckos (Eublepharis macularius) is provided. All injuries healed without scarring. Cutaneous repair involves the development of a cell‐rich aggregate within the wound bed, similar to scarring wounds. Unlike scar formation, scar‐free healing involves a more rapid closure of the wound epithelium, and a delay in blood vessel development and collagen deposition within the wound bed. It was found that, while granulation tissue of scarring wounds is hypervascular, scar‐free wound healing conspicuously does not involve a period of exuberant blood vessel formation. In addition, during scar‐free wound healing the newly formed blood vessels are typically perivascular cell‐supported. Immunohistochemistry revealed widespread expression of both the pro‐angiogenic factor vascular endothelial growth factor A and the anti‐angiogenic factor thrombospondin‐1 within the healing wound. It was found that scar‐free wound healing is an intrinsic property of leopard gecko integument, and involves a modulation of the cutaneous scar repair program. This proportional revascularisation is an important factor in scar‐free wound healing.     

Identification of a reference gene for the quantification of mRNA and miRNA expression during skin wound healing

Aim: Wound healing is a coordinated process to restore tissue homeostasis and reestablish the protective barrier of the skin. miRNAs may modulate the expression of target genes to contribute to repair processes, but due to the complexity of the tissue it is challenging to quantify gene expression during the distinct phases of wound repair. Here, we aimed to identify a common reference gene to quantify changes in miRNA and mRNA expression during skin wound healing. Methods: Quantitative real-time PCR and bioinformatic analysis tools were used to identify suitable reference genes during skin repair and their reliability was tested by studying the expression of mRNAs and miRNAs. Results: Morphological assessment of wounds showed that the injury model recapitulates the distinct phases of skin repair. Non-degraded RNA could be isolated from skin and wounds and used to study the expression of non-coding small nuclear RNAs during wound healing. Among those, RNU6B was most constantly expressed during skin repair. Using this reference gene we could confirm the transient upregulation of IL-1β and PTPRC/CD45 during the early phase as well as the increased expression of collagen type I at later stages of repair and validate the differential expression of miR-204, miR-205, and miR-31 in skin wounds. In contrast to Gapdh the normalization to multiple reference genes gave a similar outcome. Conclusion: RNU6B is an accurate alternative normalizer to quantify mRNA and miRNA expression during the distinct phases of skin wound healing when analysis of multiple reference genes is not feasible.     

Placenta growth factor in diabetic wound healing: altered expression and therapeutic potential

Reduced microcirculation and diminished expression of growth factors contribute to wound healing impairment in diabetes. Placenta growth factor (PlGF), an angiogenic mediator promoting pathophysiological neovascularization, is expressed during cutaneous wound healing and improves wound closure by enhancing angiogenesis. By using streptozotocin-induced diabetic mice, we here demonstrate that PlGF induction is strongly reduced in diabetic wounds. Diabetic transgenic mice overexpressing PlGF in the skin displayed accelerated wound closure compared with diabetic wild-type littermates. Moreover, diabetic wound treatment with an adenovirus vector expressing the human PlGF gene (AdCMV.PlGF) significantly accelerated the healing process compared with wounds treated with a control vector. The analysis of treated wounds showed that PlGF gene transfer improved granulation tissue formation, maturation, and vascularization, as well as monocytes/macrophages local recruitment. Platelet-derived growth factor, fibroblast growth factor-2, and vascular endothelial growth factor mRNA levels were increased in AdCMV.PlGF-treated wounds, possibly enhancing PlGF-mediated effects. Finally, PlGF treatment stimulated cultured dermal fibroblast migration, pointing to a direct role of PlGF in accelerating granulation tissue maturation. In conclusion, our data indicate that reduced PlGF expression contributes to impaired wound healing in diabetes and that PlGF gene transfer to diabetic wounds exerts therapeutic activity by promoting different aspects of the repair process.     

Amniotic mesenchymal stem cells enhance normal fetal wound healing

Fetal wound healing involves minimal inflammation and limited scarring. Its mechanisms, which remain to be fully elucidated, hold valuable clues for wound healing modulation and the development of regenerative strategies. We sought to determine whether fetal wound healing includes a hitherto unrecognized cellular component. Two sets of fetal lambs underwent consecutive experiments at midgestation. First, fetuses received an intra-amniotic infusion of labeled autologous amniotic mesenchymal stem cells (aMSCs), in parallel to different surgical manipulations. Subsequently, fetuses underwent creation of 2 symmetrical, size-matched skin wounds, both encased by a titanium chamber. One of the chambers was left open and the other covered with a semipermeable membrane that allowed for passage of water and all molecules, but not any cells. Survivors from both experiments had their wounds analyzed at different time points before term. Labeled aMSCs were documented in all concurrent surgical wounds. Covered wounds showed a significantly slower healing rate than open wounds. Paired comparisons indicated significantly lower elastin levels in covered wounds at the mid time points, with no significant differences in collagen levels. No significant changes in hyaluronic acid levels were detected between the wound types. Immunohistochemistry for substance P was positive in both open and covered wounds. We conclude that fetal wound healing encompasses an autologous yet exogenous cellular component in naturally occurring aMSCs. Although seemingly not absolutely essential to the healing process, amniotic cells expedite wound closure and enhance its extracellular matrix profile. Further scrutiny into translational implications of this finding is warranted.     

Regulation of scar formation by vascular endothelial growth factor

Vascular endothelial growth factor (VEGF-A) is known for its effects on endothelial cells and as a positive mediator of angiogenesis. VEGF is thought to promote repair of cutaneous wounds due to its proangiogenic properties, but its ability to regulate other aspects of wound repair, such as the generation of scar tissue, has not been studied well. We examined the role of VEGF in scar tissue production using models of scarless and fibrotic repair. Scarless fetal wounds had lower levels of VEGF and were less vascular than fibrotic fetal wounds, and the scarless phenotype could be converted to a scar-forming phenotype by adding exogenous VEGF. Similarly, neutralization of VEGF reduced vascularity and decreased scar formation in adult wounds. These results show that VEGF levels have a strong influence on scar tissue formation. Our data suggest that VEGF may not simply function as a mediator of wound angiogenesis, but instead may play a more diverse role in the wound repair process.     

胎儿和成人皮肤相关基因的差异表达

背景：胎儿皮肤创伤后无瘢痕愈合是胎儿发育过程特定阶段的特殊现象,其机制目前尚未明确,可能与调控基因的表达有关。 目的：运用人类基因芯片技术,研究人胎儿及成人正常皮肤差异表达基因及其特征和可能的生物学意义。 方法：选择人胎儿(孕20~24周)皮肤和成人(18~48岁)皮肤各10例,提取各标本的总DNA与RNA,制成荧光标记的cDNA探针,与含10 724个人类靶基因的芯片杂交,经扫描、生物信息学分析,比较两种组织基因的差异表达。 结果与结论：基因芯片高通量地揭示了胎儿及成人正常皮肤基因信息的差异表达。与成人正常皮肤比较,胎儿皮肤基因显著差异表达83个,已明确功能基因26个,涉及多种信号传递及基因调控的改变。说明胎儿与成人正常皮肤差异表达基因的存在在一定程度上导致了胎儿创伤的无瘢痕愈合。     

损伤皮肤修复和伤口愈合过程中的干细胞：问题与前景

BACKGROUND:Present treatments for chronic skin wounds have certain limitations, and adult stem cells play a potential part in cutaneous repair and regeneration. OBJECTIVE:To review effects of stem cells in skin regeneration and wound healing. METHODS:The first author retrieved CNKI and Medline databases by computer for relevant articles published from 2000 to 2010. The keywords were “epidermal stem cells, hair follicle stem cells, stem cells, transplantation, dermal stem cells” in Chinese and in English, respectively. Then totally 489 papers were obtained after initial survey, and according to the inclusion criteria, 30 articles were selected for review. RESULTS AND CONCLUSION:Epidermal stem cells and other adult stem cells have been applied to treat wounds and other skin diseases. Epidermal stem cells are the crucial cell source of skin development, repair and remodeling. Epidermal stem cells are always in a resting state in vivo. Unless, skin injure or culture in vitro, cell division and proliferation will be significantly fastened. The stability of the epidermis mainly depends on the asymmetric division of a subpopulation, in which two daughter cells are produced, including one with characteristics of stem cells, and the other differentiated into transient amplifying cells that will be differentiated into post mitotic cells after a series of cell divisions (3-5 times). Afterwards, those post mitotic cells are developed into terminal differentiation cells on the basal layer, finally detach from the epidermis as dander. In addition, it is unclear whether epidermal factors are related to apoptosis, migration and differentiation in the process of wound repair and even under physiological conditions. Therefore, application of stem cells in wound healing requires a further discussion.     

Fibrosin: a novel lymphokine in wound healing.

Several growth factors are actively synthesized during wound repair and function to stimulate different cell types involved in the process of healing. Fibrosin is a novel fibrogenic lymphokine that stimulates several biological activities that relate to in vivo scarring. To investigate the role of fibrosin, we used "punch biopsy" and linear wounding procedures in a murine model of wound healing. Histological examination showed that recombinant fibrosin stimulated epithelialization of wounds and accelerated healing of both punch biopsy and linear wounds. Fibrosin enhanced healing of linear wounds by reducing the time for healing by approximately 30-40%. From our data we estimated the healing time of control wounds to be 22-24 days; wounds treated with fibrosin appeared to heal in 14-16 days. Our observations suggest that fibrosin enhances wound healing and may be involved in accelerating epithelialization, collagen matrix formation, and also remodeling of the extracellular matrix in vivo. Thus fibrosin may function during different phases of wound healing and act as a potent inducer of scar formation and wound healing. This finding may have direct clinical applications.     

The fetal wound healing: a review.

Fetal wound healing has drawn the attention of many researchers from diverse background and specialties. Fetal wound healing is unique and differs from postnatal healing in that fetal skin wounds heal rapidly without scar formation. If the mechanism underlying such phenomenon can be elucidated, it will be serve as a significant milestone in the study of wound healing. Furthermore, the implications for therapeutic applications in wound management and in diseases where scarring is the basic pathogenetic mechanism would be immense. Rather than to list the results and conflicting data of numerous studies, this article hopes to provide a general overview of the recent developments.