References 1. Bell E, Ehrlich HP, Buttle DJ, et al: Living tissue formed in vitro and accepted as skin-equivalent tis- sue of full thickness. Science 1981; 211:1052–1054 2. Falanga V, Margolis D,Alvarez O, et al: Rapid healing of venous ulcers and lack of clinical rejection with an allogeneic cultured human skin equivalent. Arch Dermatol 1998; 134:293–300 3. Wilkins LM, Watson SR, Prosky SJ, et al: Develop- ment of a bilayered living skin construct for clinical applications. Biotechnol Bioeng 1994; 43 :747–756 4. Schmid P:Apligraf – phenotypic characteristics and their potential implications for the treatment of dia- betic foot ulcers. A satellite symposium at the 36th annual meeting of the European association for the study of diabetes (EASD). Jerusalem, September 2000 5. Phillips TJ, Manzoor J, Rojas A, et al: The longevity of a bilayered skin substitute after application to ve- nous ulcers. Arch Dermatol 2002; 138 :1079–1081 6. Navsaria HA, Myers SR, Leigh IM, et al: Culturing skin in vitro for wound therapy. Trends Biotechnol 1995; 13:91–100 7. Martin P, Hopkinson-Woolley J, McCluskey J: Growth factors and cutaneous wound repair. Prog Growth Factor Res 1992; 4 : 25–44 8. Falanga V: How to use Apligraf to treat venous ul- cers. Skin & Aging 1999; 7 :30–36 9. Fine JD: Skin bioequivalents and their role in the treatment of inherited epidermolysis bullosa. Arch Dermatol 2000; 136: 1259–1260 10. Still J, Glat P, Silverstein P, et al: The use of a collagen sponge/living cell composite material to treat donor sites in burn patients. Burns 2003; 29: 837–841 11. Pennoyer JW, Susser WS, Chapman MS, et al: Ulcers associated with polyarteritis nodosa treated with bi- oengineered human skin equivalent (Apligraf). J Am Acad Dermatol 2002; 46 :145 12. Streit M, Bohlen LM,Braathen LR: Ulcerative sarcoi- dosis successfully treated with apligraf. Dermatolo- gy 2001; 202: 367–370 13. Falabella AF,Valencia IC, Eaglstein WH,et al: Tissue- engineered skin (Apligraf) in the healing of patients with epidermolysis bullosa wounds. Arch Dermatol 2000; 136:1225–1230 14. Waymack P, Duff RG, Sabolinski M: The effect of a tissue engineered bilayered living skin analog, over meshed split-thickness autografts on the healing of excised burn wounds. Burns 2000; 26 :609–619 15. Lipkin S, Chaikof E, Isseroff Z, et al: Effectiveness of bilayered cellular matrix in healing of neuropathic diabetic foot ulcers: results of a multicenter pilot trial. Wounds 2003; 15: 230–236 16. Brem H, Balledux J, Sukkarieh T, et al: Healing of ve- nous ulcers of long duration with a bilayered living skin substitute: results from a general surgery and dermatology department. Dermatol Surg 2001; 27: 915–919 17. Steed DL, Donohoe D, Webster MW, et al: Effect of extensive debridement and treatment on the healing of diabetic foot ulcers. J Am Coll Surg 1996; 183: 61–64 18. Falanga V,Sabolinski M: A bilayered living skin con- struct (Apligraf) accelerates complete closure of hard to heal venous ulcers. Wound Repair Regen 1999; 7:201–207 19. Pham HT, Rosenblum BI, Lyons TE, et al: Evaluation of a human skin equivalent for the treatment of dia- betic foot ulcers in a prospective, randomized, clini- cal trial. Wounds 1999; 11 : 79–86 References 183 Fig. 14.6. After eight days Fig. 14.7. After 12 days 14_177_184* 01.09.2004 14:05 Uhr Seite 183 15.1 Overview The identification of topical growth factors and the development of their use in treating chronic ulcers of the skin represents a major break- through of recent years in the field of wound healing. Advanced dressing modalities have been reviewed in previous chapters. However, while various dressing materials are intended to provide an optimal environment for the healing of an ulcer, growth factors can do much more. Growth factors actually provide a significant stimulus for the healing of cutaneous ulcers: They not only function as an external cover that may provide optimal conditions for repair, but also actually initiate and enhance the wound healing process. The effect of certain therapeu- tic modalities in wound healing involving living cell grafting, such as cultured keratinocyte grafts or composite grafts, is attributed, in part, to the stimulation of various cells within the treated ulcer to secrete endogenous growth factors, thereby enhancing the healing process [1–5]. 15.2 What Are Growth Factors? Growth factors are a specific subgroup of cyto- kines, whose main activity is the induction of mitosis. They are secreted by a wide range of cells including macrophages, fibroblasts, endo- thelial cells, and platelets [6]. Many cytokines have been identified as hav- ing a role in wound healing. These include platelet-derived growth factor (PDGF), fibro- blast-derived growth factor (FGF), epidermal growth factor (EGF), tumor necrosis factor (TNF), granulocyte-macrophage colony-stimu- lating factor (GM-CSF), insulin-like growth fac- tor (IGF), transforming growth factors (TGF) α and β, and many others. Growth Factors 15 Contents 15.1 Overview 185 15.2 What Are Growth Factors? 185 15.3 Beneficial Effects of Growth Factors on Acute Wounds and Chronic Cutaneous Ulcers 186 15.4 Recombinant Human Platelet-Derived Growth Factor: rhPDGF (Becaplermin) 186 15.5 Research Studies Using Recombinant Human PDGF 187 15.6 PDGF: Indications and Contraindications 187 15.7 Mode of Using PDGF Gel Preparation 188 15.8 Topical Use of Other Growth Factors 188 15.8.1 Granulocyte-Macrophage Colony-Stimulating Factor 189 15.8.2 Epidermal Growth Factor 189 15.9 Anti-Infective Effects of Growth Factors 190 15.10 Summary and Future Research 190 References 190 I ndiana Jones pours the water over the wound and everyone watches in astonishment as the wound and the blood stain disappear before their eyes. (From the screenplay ‘Indiana Jones and the Last Crusade’ by J. Boam, story by Lucas & Meyjes) ’’ 15_185_192 01.09.2004 14:05 Uhr Seite 185 Growth factors exert their effect on cells through cell-surface receptors. They may bind to one or several receptors. In the process of wound healing, endogenous growth factors co- ordinate cellular migration including chemo- taxis of inflammatory cells. They have a mito- genic effect on epithelial cells, by inducing their proliferation and differentiation with enhance- ment of epithelial regeneration. They also exert a mitogenic effect on mesodermal cells, mani- fested as stimulated angiogenesis and granula- tion tissue formation.Growth factors also influ- ence and regulate the degradation and forma- tion of collagen [6–15]. Note that the current terminology used for growth factors does not adequately present an accurate description of their biological activity. In most cases, the original naming of each growth factor is associated with the circum- stances of its biochemical identification, de- rived from what has been considered previous- ly as its ‘source cell’. The equivocal terminology associated with growth factors in the scientific literature exists, in fact, to a much wider extent. Thus, apart from being secreted by platelets, platelet-de- rived growth factor (PDGF) is also secreted by a wide range of cells including macrophages, fi- broblasts, and endothelial cells. Various peptides that activate cellular reac- tions similar to those of growth factors may be called interleukins or colony-stimulating fac- tors; yet, by the same token, it would also be sci- entifically justified to refer to these peptides as growth factors. 15.3 Beneficial Effects of Growth Factors on Acute Wounds and Chronic Cutaneous Ulcers In animal models, research studies have shown that growth factors may enhance the process of healing in acute wounds [12, 16–21]. Several studies have demonstrated the beneficial ef- fects of growth factors on the healing of acute wounds in human beings, i.e., split-thickness donor sites [22, 23] or punch wounds to normal skin [24]. Preparations containing growth factors are used mainly for chronic cutaneous ulcers. Cur- rent evidence indicates that in chronic cutane- ous ulcers, for reasons that are not fully under- stood, the process of wound healing is arrested. Hence, a chronic ulcer remains in an ongoing inflammatory phase, rather than proceeding through the phases of healing, as occurs in a ‘healthy’ acute wound [25, 26]. Studies of wound fluid in chronic cutaneous ulcers have revealed an increased protease ac- tivity with the breakdown of growth factors [27–31]. The reduced activity of growth factors in chronic ulcers may partly explain why these ulcers sometimes fail to heal.The use of prepar- ations containing growth factors in the treat- ment of chronic cutaneous ulcers may over- come this stagnatory state, thereby stimulating the repair process and facilitating wound heal- ing. Today, advances in molecular biology have enabled the production of large amounts of growth factors by recombinant DNA technolo- gies. Hence, specific growth factors may be used to enhance wound healing. In this process, there is interaction between various growth factors and the induction of stimulatory or in- hibitory effects. Therefore, a specific growth factor may act at several stages in the course of healing of an ulcer or a wound. However, when used individually, certain growth factors have not been found not to promote healing in prac- tice, since they affect only specific sites in the chain of processes. A few cytokines, such as TGF β,GM-CSF, and PDGF have been known to influence several key steps in the wound heal- ing process [6, 7, 12, 13, 32–36]. Currently, only PDGF is commercially available. Hence, PDGF will be discussed in detail below. 15.4 Recombinant Human Platelet-Derived Growth Factor: rhPDGF (Becaplermin) Initial observations have demonstrated that a platelet-derived growth factor (PDGF), stored in α granules of circulating platelets, is released following injury as part of the process of blood clotting. However, in the human body, PDGF is Chapter 15 Growth Factors 186 15 15_185_192 01.09.2004 14:05 Uhr Seite 186 secreted by a wide range of cells, including macrophages, fibroblasts, and endothelial cells. It regulates numerous aspects of wound healing including chemotaxis of inflammatory cells and mitogenesis in mesodermal and epithelial cells and enhances epithelial regeneration [36–39]. Of the growth factors currently under inves- tigation, PDGF has shown beneficial effects in phase III clinical trials, and it is the only one commercially available (Regranex gel®). The commercial topical preparation is produced us- ing recombinant DNA technology. The gene for the β chain of PDGF is inserted into the yeast Saccharomyces cerevisiae – a process that en- ables production of high amounts of this com- pound [40]. It is manufactured in tubes of 7.5 g or 15 g as an aqueous-based sodium carboxy- methyl cellulose topical gel containing 0.01% recombinant human PDGF. In clinical use, PDGF has been shown to in- crease the formation of granulation tissue (manifested by the continuous flattening of rel- atively deep cutaneous ulcers) and the concur- rent coverage of the wound surface by layers of regenerative epithelium. Several research stud- ies [41–46] in which it was compared with a placebo gel have shown it to be of benefit in di- abetic foot ulcers. In 1997, it was approved for clinical use in North America and in the Euro- pean Union for treating diabetic neuropathic ulcers of the lower extremities. Currently, there are many ongoing studies investigating the effect of PDGF on other types of wounds and chronic ulcers. Promising re- sults of its use in the management of pressure ulcers [47–49] and radiation ulcers [50] have al- so been reported. Recently,Wieman document- ed the beneficial effect of PDGF, together with good wound care based on compression thera- py, in the treatment of patients with chronic ve- nous leg ulcers [51]. 15.5 Research Studies Using Recombinant Human PDGF Wieman et al. [41] conducted a multicenter, double-blind, placebo-controlled study in 1998 that included 382 patients with chronic neuro- pathic diabetic ulcers that had been present for more than eight weeks. Following 20 weeks of treatment with recombinant human PDGF, 50% of the treated ulcers healed, compared with a 35% healing rate in the control group treated with a placebo preparation. In addition, the time needed to achieve complete wound clo- sure was reduced by 32%. In another study, Steed et al. [42] also dem- onstrated the efficacy of rhPDGF. Twenty-nine of 61 patients (48%) with diabetic neuropathic ulcers treated with rhPDGF healed within 20 weeks, compared with a healing rate of 25% (14 of 57 patients) in placebo-treated ulcers. In 1999, Smiell et al. [44] summarized the combined results of four multicenter, random- ized studies that evaluated the efficacy of rhPDGF.A total of 922 patients with diabetic ul- cers in the lower legs were treated once a day with a topical preparation containing either 100 µg/g rhPDGF, 30 µg/g rhPDGF, or placebo. Patients were treated until complete healing was achieved, or for a period of 20 weeks. A program of good ulcer care was given to all treatment groups, including initial sharp debridement (and additional debridement if necessary throughout the research project), a non-weight-bearing regimen, systemic antibio- tics when needed (for infected wounds), and moist saline dressings. The 100-µg/g rh PDGF preparation was shown to significantly de- crease the time to achieve complete healing compared with the placebo gel. Other research studies indicating the benefi- cial effect of PDGF on diabetic ulcers have also been published [45, 46]. Note that PDGF has been shown to have a beneficial effect not only on chronic cutaneous ulcers, but also on acute wounds. Cohen and Eaglestein [24] conducted a double-blind controlled study, in which PDGF was applied to punch biopsy wounds on nor- mal skin of healthy volunteers and was found to speed up the healing rate of the treated wounds. 15.6 PDGF: Indications and Contraindications PDGF is intended for use only on a clean (or a relatively clean) ulcer. In any case, superficial 15.6PDGF: Indications and Contraindications 187 15_185_192 01.09.2004 14:05 Uhr Seite 187 debridement is needed (see below). For the time being, it has been approved for use only on non-infected diabetic foot ulcers. Contraindications to the use of PDGF, as presented by the manufacturer are: 5 Infected ulcers 5 Known hypersensitivity to a compo- nent of the preparation (e.g., the parabens) 5 Neoplasm in the application site 15.7 Mode of Using PDGF Gel Preparation The ulcer should be thoroughly rinsed prior to the application of a PDGF preparation. The superficial outer layer of a cutaneous ulcer should be debrided and removed prior to the application of PDGF gel. Debridement should extend (very superficially) to viable healthy tis- sue until a minor degree of bleeding (pinpoint bleeding) is achieved, and vital granulating tis- sue is exposed (see Chap.9, Section 9.4.1.1). This creates a more vascular bed, providing a better substrate for the wound-healing process. In ad- dition, the superficial debridement removes a fibrin superficial layer (which, although almost invisble, may still prevent the preparation from coming into direct contact with the ulcer bed). In a retrospective study conducted by Steed et al. [52], better healing rates were achieved in centers where ulcers were debrided more fre- quently. Some suggest that superficial, very deli- cate debridement may be repeated every 7–10 days; however, extreme care should be taken not to remove the newly forming epithelial layer. After any minor bleeding has ceased, a very thin layer (approximately 0.2 cm thick) of PDGF gel is applied to the ulcer. The prepara- tion should be spread over the ulcer surface with an application device, such as a tongue de- pressor, in order to obtain an even and continu- ous layer (Fig. 15.1). Subsequently, the wound should be covered with gauze. The amount of preparation required depends on the ulcer’s surface area. The manufacturer’s directions suggest that each square inch of sur- face area requires a length of approximately 2/3 - inch of gel preparation, squeezed from a stan- dard tube (7.5 g or 15 g). In metric terms, each square centimeter of the ulcer’s surface area re- quires a length of 0.25 cm of gel preparation from a standard tube. The physician should re- evaluate the required amount of preparation needed, depending on the current surface area, every 1–2 weeks. The preparation should be changed once daily; provided that the previously applied preparation is rinsed off with normal saline so- lution each time. Note that PDGF gel should be kept in the refrigerator. Room temperature may damage the preparation. It should not be kept in the freezer. 15.8 Topical Use of Other Growth Factors Although PDGF is the only growth factor that has been licensed for use, other growth factors have been shown to be effective when used on experimental wounds or cutaneous ulcers. In view of the large extent of this issue, we discuss below only growth factors whose effects have been documented on humans. For example, in randomized, double-blind placebo-controlled research studies,Robson et al. [53] have demon- Chapter 15 Growth Factors 188 15 t Fig. 15.1. Application of the preparation onto the ulcer’s surface with a tongue depressor 15_185_192 01.09.2004 14:05 Uhr Seite 188 strated a beneficial effect of recombinant basic fibroblast growth factor (FGF) on patients with stage III/IV pressure sores. FGF has also been shown to accelerate wound healing in burns, split-thickness skin graft donor-site wounds, and chronic cutaneous ulcers [23]. Similarly, topically applied recombinant human keratino- cyte growth factor-2 was shown to accelerate the healing of venous ulcers [54]. Other studies have examined the effect of various growth factors including TGF-β,insu- lin-like growth factors, and interleukin-1-β on acute wounds and chronic cutaneous ulcers [55, 56]. Nevertheless, at present, the two growth factors that have been studied the most inten- sively (in addition to PDGF) are GM-CSF and EGF. 15.8.1 Granulocyte-Macrophage Colony-Stimulating Factor In vivo research studies have shown that rhGM- CSF may enhance wound healing by affecting several healing mechanisms, including the in- duction of myofibroblast differentiation, the mobilization of white blood cells, and the stim- ulation of proliferation and migration of epi- thelial cells [32, 57]. Perilesional GM-CSF. A few case reports have suggested that using perilesional rhGM- CSF on chronic cutaneous ulcers may be effec- tive [58– 60]. More solid evidence may be de- rived from two randomized, double-blind, pla- cebo-controlled studies. Da Costa et al. [61] documented the effect of rhGM-CSF injected subcutaneously adjacent to the ulcer margin in 25 patients with chronic venous ulcers. In eight of 16 (50%) patients treated with GM-CSF, there was complete healing within eight weeks, com- pared with a healing rate of 11% (one of nine) in control patients, treated with injections of saline solution. In another double-blind, placebo-controlled study conducted by Da Costa et al. [62], 60 pa- tients with chronic venous leg ulcers were treat- ed by perilesional injections of rhGM-CSF. Complete healing was achieved within 12–14 weeks in 57% of patients treated with a 200-mg preparation of GM-CSF and in 61% of patients treated with a 400-mg preparation of GM-CSF, but in only 19% of the placebo group. Topical GM-CSF. The most convincing study documenting the beneficial effect of topical GM-CSF has been provided by Jaschke et al. [63], in which 52 venous ulcers were treated with a topical preparation containing 0.5–1.0 g/ cm 2–3 times weekly. Ninety percent of the ul- cers healed completely, with an average healing time of 19 weeks. Several other studies have al- so given credence to the hypothesis that topical GM-CSF is of benefit [64–66]. 15.8.2 Epidermal Growth Factor Epidermal growth factor (EGF) is a single poly- peptide chain consisting of 53 amino acids orig- inating mainly from macrophages and monocy- tes. It was the first growth factor isolated from urine, saliva, breast milk, and amniotic fluid; this was followed by its biochemical identifica- tion [67–69].Initial animal studies conducted in the 1980s showed that EGF induces epidermal proliferation and angiogenesis [70, 71]. In 1989, Brown et al. [22] conducted a ran- domized, double-blind study on 12 patients, each with two skin graft donor sites.In each pa- tient, one donor site was treated with silver-sul- fadiazine, while the other was treated with sil- ver-sulfadiazine containing EGF. There was im- proved healing at the donor sites treated with the silver-sulfadiazine/EGF combination, com- pared with those treated with silver-sulfadia- zine only. In 1992, Falanga et al. [72] used an aqueous solution of 10 g/ml human recombinant EGF, applied twice daily to venous ulcers. The prep- aration was applied for up to 10 weeks or until complete healing was achieved. Of the 18 pa- tients treated with the EGF solution, complete healing was achieved in six (35%), while only two of the 17 patients (11%) in the control group were healed completely. The median reduction in ulcer size was 73% in the EGF group, com- pared with 33% in the control group. Though the above data look promising, there have been no well-documented studies of EGF since 1992. 15.8Topical Use of Other Growth Factors 189 15_185_192 01.09.2004 14:05 Uhr Seite 189 Other members of the EGF family are li- gands of the receptor EGF-R that share similar proliferative activity in the epidermis. These are transforming growth factor α (TGF-α), am- phiregulin, and heregulin. Yet, for the time be- ing, EGF is the only member of this group whose effects on wounds and ulcers have been documented. 15.9 Anti-Infective Effects of Growth Factors In addition to their effect on healing, growth factors may also possess certain features that assist human tissues in coping with infection. Some aspects of this issue are obvious: Through induction of angiogenesis, for exam- ple, and improved vascularization of affected tissues, the ability to overcome infection is in- creased. There may be other ways in which growth factors enhance the immune function of pa- tients. For example, granulocyte colony-stimu- lating factor (G-CSF) has been shown to have a beneficial effect on foot infection in diabetic patients, which is attributed to improvement in neutrophil function [73]. De Lalla et al. [74] demonstrated that the administration of G-CSF for three weeks as an adjunctive therapy in limb-threatening diabetic foot infections was associated with better clinical outcomes, i.e., fewer cases of infection leading to the need to amputate the affected limb. The question as to whether growth factors actually secrete any ac- tive anti-bacterial substances requires further research. 15.10 Summary and Future Research Advances in the field of molecular biology have enabled the production of highly purified re- combinant human proteins. For the time being, PDGF is the only growth factor commercially available. Its beneficial effects on cutaneous ulcers have been demonstrated in numerous clinical trials. In addition to PDGF, several oth- er growth factors are currently being investi- gated. Future research may focus on: 5 Combining growth factors with skin grafts, various skin substitutes, and tissue engineering products 5 Matching and adapting growth fac- tors to specific types of cutaneous ulcers or wounds, depending on their etiology or clinical appearance 5 Identifying and using the anti-infec- tive potential that certain growth factors may possess, thereby extend- ing their use to infected cutaneous ulcers References 1. Leigh IM,Purkis PE,Navsaria HA,et al: Treatment of chronic venous ulcers with sheets of cultured allo- genic keratinocytes. Br J Dermatol 1987; 117 :591–597 2. Phillips TJ,Gilchrest BA: Cultured allogenic keratin- ocyte grafts in the management of wound healing: prognostic factors. J Dermatol Surg Oncol 1989; 15 :1169–1176 3. Stanulis-Praeger BM, Gilchrest BA: Growth factor re- sponsiveness declines during adulthood for human skin-derived cells.Mech Ageing Dev 1986; 35: 185–198 4. 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Gough A, Clapperton M, Rolando N, et al: Random- ized placebo-controlled trial of granulocyte-colony stimulating factor in diabetic foot infection. Lancet 1997; 350 :855–859 74. De Lalla F, Pellizzer G, Strazzabosco M, et al: Ran- domized prospective controlled trial of recombi- nant granulocyte colony-stimulating factor as ad- junctive therapy for limb- threatening diabetic foot infection. Antimicrob Agents Chemother 2001; 45 : 1094–1098 Chapter 15 Growth Factors 192 15 15_185_192 01.09.2004 14:05 Uhr Seite 192 16.1 Overview This chapter deals with the association between medications and the wound healing process. Schematically, three major categories of medications may be considered: 5 Drugs that directly ulcerate the skin (whether by injection, topical use, or systemic administration) 5 Drugs that interfere with the natural wound healing process 5 Drugs that affect skin quality in general This classification into three categories is somewhat artificial, and in many cases there is an overlap between the various types of effects listed above for a given drug. For example, it is reasonable to assume that each medication that directly causes ulcers (e.g., a drug that induces systemic lupus erythematosus), interferes with the healing of existing ulcers as well. Drugs such as calcium blockers, which may cause leg edema,may serve as another example. Edema, in itself, has a generally adverse effect on the skin.As a result, the skin is more vulner- able,and even trivial trauma can result in ulcer- ation. At the same time, since the skin’s overall quality is adversely affected, it is reasonable to assume that its ability to heal is diminished, even for pre-existing ulcers. Nevertheless, for the sake of simplicity,in this chapter we restrict ourselves to the three-category classification. A major issue presented is the category of medications that directly cause ulceration. In Drugs,Wound Healing and Cutaneous Ulcers 16 Contents 16.1 Overview 193 16.2 Ulceration at the Injection Site 194 16.2.1 Injections for Therapeutic Purposes – Subcutaneous or Intramuscular 194 16.2.2 Injection for Therapeutic Purposes – Extravasation 196 16.2.3 Accidental Injections 196 16.2.4 Drug Abuse 196 16.2.5 Self-Inflicted Ulcers 197 16.3 Direct Cutaneous Exposure 198 16.4 Systemic Drugs that Directly Induce Ulceration 198 16.4.1 Causing or Aggravating Certain Diseases 198 16.4.2 Induction of Vasculitis 199 16.4.3 Vasospasm 199 16.4.4 Drugs Affecting Coagulability 199 16.4.5 Drugs Causing Bullae 200 16.4.6 Unidentified Mechanisms 200 16.5 Interference with Normal Mechanisms of Wound Healing 200 16.5.1 Glucocorticoids 201 16.5.2 Non-Steroidal Anti-inflammatory Drugs 202 16.5.3 Anti-Neoplastic and Immunosuppressive Drugs 202 16.5.4 Other Drugs that Interfere with Healing 202 16.6 Drugs that Adversely Affect Skin Quality 202 16.6.1 Leg Edema 202 16.6.2 Skin Atrophy or Scleroderma-Like Reactions 203 References 203 t 16_193_208 01.09.2004 14:06 Uhr Seite 193 [...]... Medications such as aspirin and ibuprofen have been shown to impair collagen production and to lower the tensile strength of healing wounds [131, 132] Whether the effect of non-steroidal anti-inflammatory drugs (NSAID) on the healing of cutaneous wounds is similar to their effect on gastric mucosa requires further investigation The extent to which the healing of cutaneous ulcers is hampered by NSAID... by the appearance of swelling and redness in the area of injury, accompanied by pain Induration at the extravasation site may develop into an ulcer within a period of weeks or months t 16_193_2 08 The extent of ulceration depends on the: 5 Type of offending drug 5 Amount of extravasated material 5 Site of extravasation: more severe reactions tend to develop on the dorsum of the hand and in the area of. .. Dermatol 1 988 ; 27 : 59–62 1 18 Surville-Barland J, Caumes E,Ankri A, et al: Bleomycin-induced digital gangrene Eur J Dermatol 19 98; 8 : 221 119 Green JP: Steroid therapy and wound healing in surgical patients Br J Surg 1965; 52 : 523–525 120 Anstead GM: Steroids, retinoids, and wound healing Adv Wound Care 19 98; 11 : 277– 285 121 Pollack SV: Wound healing: A review 4 Systemic medications affecting wound healing. .. administration of cortisone and wound healing in rats Acta Chir Scand 1964; 127 : 446–455 131 Kulick MI, Smith S, Hadler K: Oral ibuprofen: evaluation of its effect on peritendinous and the breaking strength of a tenorrhaphy J Hand Surg [Am] 1 986 ; 11 : 110–120 132 Lee KH: Studies on the mechanism of action of salicylates 3 Effect of vitamin A on the wound healing retardation action of aspirin J Pharm Sci 19 68; ... [123–126]; wound contraction is impaired and reduced synthesis of proteins and collagen further delays the normal course of wound healing and closure of cutaneous ulcers [127, 1 28] Research studies have shown that if glucocorticoids are administered within the first three days following injury, the effect on wound healing is much more significant than if they are administered more than three days after the. .. with Normal Mechanisms of Wound Healing In most cases, drugs belonging to this group do not cause ulceration directly These drugs may interfere with the healthy physiological mechanisms of wound healing, and their use may significantly impede the healing of existing ulcers Glucocorticoids are the most notorious drugs of this group, in respect to their influence on heal- 16_193_2 08 01.09.2004 14:06 Uhr... cutaneous ulcers, one should consider avoiding the use of NSAID and using alternative analgesic drugs At present, there are no data regarding whether the use of advanced forms of NSAID may have a certain advantage with respect to their effect on healing 16.5.3 Anti-Neoplastic and Immunosuppressive Drugs Observations that anti-neoplastic and immunosuppressive drugs interfere with the normal course of wound healing, ... characteristic gel is obtained from the inner part of the aloe leaf; this gel has been used for centuries for skin afflictions and wounds Mode of Action In contrast to other alternative medications, the effects of aloe vera extracts on wound healing have been examined rather closely The picture is still not clear, but 17.2 there are several possibilities The main thrust of the research suggests that aloe... the mechanism by which antineoplastic drugs exert their effects on the healing of cutaneous ulcers is not fully understood Some of these effects may be attributed to nutritional deficiencies and the catabolic effects associated with these drugs [135–137] In any case, the identification and correction of nutritional deficiencies may prevent the negative consequences of anti-neoplastic treatment on healing. .. anti-neoplastic treatment on healing of wounds and chronic ulcers of the skin The issue of extravasation injury following intravenous injections of anti-neoplastic drugs is discussed above 16.5.4 Other Drugs that Interfere with Healing Colchicine has been shown to delay the normal course of wound healing This effect may be due to its inhibitory effect on tubulin-dependent cell functions, including . [123–126]; wound contraction is im- paired and reduced synthesis of proteins and collagen further delays the normal course of wound healing and closure of cutaneous ulcers [127, 1 28] . Research. production and to lower the tensile strength of healing wounds [131, 132]. Whether the effect of non-steroidal anti-inflammatory drugs (NSAID) on the heal- ing of cutaneous wounds is similar to their. extremities. Currently, there are many ongoing studies investigating the effect of PDGF on other types of wounds and chronic ulcers. Promising re- sults of its use in the management of pressure ulcers [47–49] and