Reviews in Endocrine and Metabolic Disorders

https://doi.org/10.1007/s11154-019-09492-1

Role of growth factors and cytokines in diabetic foot ulcer healing: A

detailed review
Mohammad Zubair 1 & Jamal Ahmad 2

# Springer Science+Business Media, LLC, part of Springer Nature 2019

Abstract
The aim of the review is to examine the role of growth factors and cytokines in the management of Diabetic Foot Ulcers, such as
platelet derived growth factor (PDGF), vascular endothelial growth factor (VEGF), fibroblast growth factor (FGF) and Insulin
like growth factor (IGF). Taking this a step further, the role of Hypoxia-inducible factors (HIFs), Transforming growth factor beta
1 (TGF-β-1) and other growth factors have also been examined, with regard to the treatment of diabetic foot ulcers. The roles of
these above-mentioned growth cytokines have been analyzed by studying various scholastic articles. The complete process of
wound healing is implemented and regulated by numerous cytokines and human growth factors. The findings of the study
indicate that wound healing of diabetic foot ulcers is a complex and extremely challenging biological and molecular process that
involves coordinated efforts of multiple cell types. The therapeutic effects of various growth factors in the clinical management of
wounds are chronic venous ulcers, pressure ulcers, and diabetic foot ulcers. It has been concluded that altercations of various
cytokines are found in patients enduring diabetic foot ulcers. In a similar way, changes in the level of cytokines are also found in
patients suffering from other diabetic complications such as diabetic nephropathy, retinopathy, and neuropathy. Subsequently, the
diabetic wound healing process can be accelerated by regulating the levels of the cytokines.

Keywords Cytokines . Diabetic ulcers . Growth factors . Molecular process . Wound healing . Mechanism . Vascular endothelial
growth factor . Insulin

1 Introduction of insulin-producing pancreatic cells; whereas type 2, results

from the peripheral resistance of insulin [1]. The prevalence
People suffering from diabetes endure long-term complications of diabetes is widespread and has been growing in epidemic
such as cardiovascular diseases, nephropathy, retinopathy, neu- proportions. Currently, the disease affects 422 million adults
ropathy and diabetic ulcers in the lower limbs. Amongst these worldwide according to the report of the World Health
complications, peripheral neuropathy and diabetic ulcers in the Organization [2], which is expected to reach 693 million figure
lower limbs have long-ranging negative effects on diabetic pa- by 2045 [3]. As a result, the probability of the number of pa-
tients. Diabetes mellitus embodies a group of diverse metabolic tients enduring long-term complications such as cardiovascular
disorders that arise as a result of hyperglycemia due to a defi- diseases, nephropathy, retinopathy, neuropathy and diabetic ul-
ciency in secretion of insulin and insulin action. There are three cers in the lower limbs also increases. Among these complica-
categories of diabetes, namely; Type 1, Type 2 and gestational tions, peripheral neuropathy and diabetic ulcers in the lower
diabetes. Type 1 diabetes occurs ensuing from the destruction limbs is responsible for a greater number of hospital admis-
sions, with annual expenditures on its care reaching five billion
dollars in the United States only. Furthermore, it is predicted
* Mohammad Zubair that one in four patients with diabetes will develop chronic foot
[email protected]
injuries at some point in their lives [4].
It has been noticed that people with diabetes are often ob-
1
Department of Medical Microbiology, Faculty of Medicine, served to develop diabetic neuropathy which results as an
University of Tabuk, Tabuk 71491, Kingdom of Saudi Arabia
outcome of the neurovascular factors. The toes, legs, feet,
2
Rajiv Gandhi Centre for Diabetes and Endocrinology, Faculty of and arms experience loss of feeling as well as pain in the
Medicine, J.N. Medical College, Aligarh Muslim University,
peripheral neuropathy as a result of low blood flow and
Aligarh 202002, India
 Rev Endocr Metab Disord

damage of the distal nerve. The areas of the feet which are expression of cytokines and growth factors. The wound
numb i.e. metatarsophalangeal joints or the heel region are healing process in diabetic foot ulcers (DFU) involves granu-
observed to have a blister or become soar [5]. The applied lation, vascularization, epidermal regeneration, and recruit-
pressure on the feel is due to the presence of unnoticeable ment of endothelial precursors [10]. In the molecular physiol-
numbness. The blisters and sores in due course become a ogy, it has been discovered that there are fewer endothelial
portal of entry for bacteria, which leads to infection. The cur- progenitor cells (EPCs), greater inflammation, and fewer
rent expenditure deployed for treatment is 2.3 times higher as growth factors present in the wounds of people suffering from
compared to the expenditure in the absence of diabetes [6]. diabetes. Most importantly, deficiencies in growth factors
The increasing rate of the expenditure and reported cases em- such as Platelet-derived growth factor (PDGF), keratinocyte
phasize the investigation of the factors which causes diabetes growth factor (KGF), transforming growth factor-beta
in patients. Various recent advancement has been reported in (TGF-β) and vascular endothelial growth factor (VEGF),
the growth factor required for the healing of the wound and have all been involved in the delayed healing rates that as
advancing its progress [7]. This promotes the performance of noticed in chronic diabetic wounds [11]. Cytokines are small
the study to highlight the new changes, which are taking place proteins, which are soluble in the serum and are implicated in
in the growth factors and cytokine causing increased cases of interacting with cell surface receptors. Furthermore, they serve
foot ulcer in individuals with diabetes. as a communication network between cells. Cytokines acti-
vate signal cascade by interacting with specific transmem-
brane receptors that result in an optimum cellular response.
2 Mechanism of ulcer formation

Ulcers in diabetic patients can be defined as lesions and abra- 3 Molecular steps involved in healing of ulcer
sions that involve loss of epithelium. They may extend to the in diabetic patients
dermis and deeper layers, sometimes involving bones and
muscles. Foot ulcers in diabetic patients take a long time to To understand the pathophysiology in diabetes inhibition,
heal due to a series of molecular and cellular peculiarities of the role of the growth factors has to been examined closely.
the healing process, being the main ones: high concentration Growth factors have been associated with mediating the
of metalloproteinases (MMPs), neuropathy, high probability normal healing process but have played an indispensable
of infection and non-physiological inflammatory response, role in impaired wound healing. Cytokine growth factors,
oxidative stress. In addition, they may also include the exces- including PDGF, FGF, EGF, VEGF, IGF, TGF and others
sive formation of AGEs (Advanced glycation end products), accelerate and augment wound healing through their phys-
deficient neoangiogenesis, insufficient concentrations of iologic actions. Cytokine growth factors play an essential
growth factors, the imbalance between metabolism and nutri- role in the choice of wound healing and influence many
ent delivery, cellular abnormalities and regulators of gene ex- processes, including the proliferation and migration of var-
pression [8] (Fig. 1). ious cell types, endothelial cell stimulation, angiogenesis
The healing of the wounds requires cellular activation for and chemotaxis of fibroblasts and inflammatory cells.
the injury involving the actions of keratinocytes, endothelial Cytokine growth factors also assist in preventing apoptosis
cells, fibroblasts, platelets, and macrophages [9]. The hypoxia and influence the production and remodeling of the extra-
inducement followed by the release of vascular endothelial cellular matrix. The orderly and sequential progression
growth factor (VEGF) by macrophages, fibroblasts, and epi- through the stages of wound healing requires a number of
thelial cells initiates the phosphorylation and endothelial nitric different humoral factors, cells, and other agents to interact
oxide synthase (eNOS) activation for healing. The process in such a way that timely and proper closure of the wound
slows down in the diabetic patient as compared to the healthy occurs. Abnormalities and irregularities in any of these
individual as a result of the blood sugar level. The EPC in the ways may result in pathologic wound healing from chron-
diabetic patients does not receive signal, which is essential for ic, nonhealing wounds to hypertrophic scar formation or
the location of the wound site, and healing process decreases keloid. Growth factors such as PDGF and IGF act to inhibit
as a result of mitigated angiogenesis [9], as exhibited in Fig. 1. the apoptosis pathways [12, 13]. These growth factors are
Wound healing occurs as a cellular response to injury and essential for the rapid turnover of cells, which is required
involves activation of keratinocytes, macrophages, fibro- to enable different stages of physiologic wound healing.
blasts, endothelial cells, and platelets. Many growth factors
and cytokines released by these cell types are needed to coor- 3.1 Role of PDGF
dinate and maintain healing. Many factors are associated with
healing impairment in diabetes. Some of these are vascular Platelet-derived growth factor (PDGF) is a crucial element
disease, diminished re-epithelialization and imbalanced in wound healing and its influence cannot be overstated.
Rev Endocr Metab Disord

Fig. 1 Molecular representation of differences in healthy wound and diabetic wound (adopted with licence (No. 4544721457776) from Brem H and
Tomic-Canic M 2007 [62])

PDGF has been the first recombinant growth factor ap- FGFs are more powerful angiogenic factors than PDGF
proved for topical application to accelerate wound clo- and VEGF [15]. FGFs stimulate angiogenesis and the
sure. In a blood vessel, formation or angiogenesis, the proliferation of fibroblasts that give rise to granulation
growth of blood vessels from already-existing blood ves- tissue. The tissue fills up wound space and wound cavity
sel tissue PDGF is released by the platelets and secreted in the initial stage of the wound healing process.
by activated macrophages with concentrations. In the be-
ginning stage of wound healing, PDGF serves as a chemo 3.3 Role of KGF
attractant for the migration of fibroblasts, neutrophils, and
monocytes to the site of injury [14]. PDGF encourages the The keratinocyte growth factor (KGF), is a growth factor pres-
production of new extracellular matrix components and is ent in the epithelialization phase of the wound healing process.
a mitogen for fibroblasts. Furthermore, PDGF stimulates Keratinocytes cover the wound and form the epithelium in the
the differentiation of fibroblasts into myofibroblasts, facil- epithelialization phase and stimulate collagen deposition in
itating the contraction of collagen matrices and the wound the healing wound [16]. Apart from this, KGFs encourage
in the proliferation stage. the repair of mucosal tissues and injured skin by stimulating
the migration, proliferation, and differentiation of epithelial
3.2 Role of FGF cells. At the same time, tissue remodeling is directly impacted
by the chemotactic effects of the KGF.
The fibroblast growth factors (FGF) are a family of cell
signaling proteins that are involved in a wide variety of 3.4 Role of VEGF
processes, most importantly for the process of normal de-
velopment. Likewise, any anomalies in their function lead Vascular endothelial growth factors (VEGF) comprise of a
to a range of developmental defects. Some of the func- family of cytokine growth factors. They have been recognized
tions comprise of neural development, keratinocyte orga- as important intermediaries of vascular permeability angio-
nization, and angiogenesis and wound healing processes. genesis and lymphangiogenesis. Similarly, VEGF encourages
 Rev Endocr Metab Disord

collagen deposition and epithelialization in wound healing for fibroblasts and keratinocytes and stimulates the production
[16]. The production of VEGF lies at the downstream of hyp- of extracellular matrix component [25].
oxia as it binds to the receptors present on the endothelial
cells, which further directs the growth of the vessels. 3.7 Role of TGF-β-1

Transforming growth factor beta 1 (TGF-β-1) is a polypeptide

3.5 Role of interleukins
member of the transforming growth factor beta superfamily of
cytokines. TGF-β-1 is a protein that executes various cellular
Interleukins (IL) are important inflammatory molecules pro-
functions and is implicated in the control of cell growth, cell
duced by blood monocytes and tissue macrophages [17].
differentiation, cell proliferation and apoptosis [25]. Diabetes
Leukocytes manufacture these cytokines, and these interleu-
is connected with persistent inflammation and defective tissue
kins are secreted towards the target cell to bond on the surface
repair responses. TGF-β-1 reverses and prevents the stimula-
when a human body is attacked by an infectious agent. This
tion of macrophages by blocking the signaling through the
activates the signals within the target cells, thereby, changing
receptor pathways. An increased level of TGF-β-1 is linked
the behavior of the cells. Elevated IL levels have been impli-
with type 2 diabetes. It moderates the buildup of extracellular
cated in the development of insulin resistance and anomalous
matrix (ECM) that leads to a decrease in the number of func-
healing in diabetes. In patients with duodenal and gastric ul-
tional cells. This results in the weakening of the renal
cers, numerous interleukins such as IL-8, IL-10, and IFN-y
reabsorptive and excretory function [26].
have been implicated in the inflammatory process in gastric
mucosa inflammation [18]. Patients with diabetic foot ulcers
3.8 Role of miR-146a
have increased levels of interleukins and these levels decrease
as the ulcers heal. Diabetic foot wound treatment with the
The microRNA-146a (miR-146a) expression is deliberate-
Interleukin-22 has shown to significantly quicken the healing
ly reduced in the wound among people diagnosed with
process, by encouraging vascularization, re-epithelialization,
diabetes [27]. This correlates with an increased expression
and granulation tissue formation. It also enhances VEGF re-
of its target genes IRAK1 and TRAF6. The miR-146a
lease and inhibits diabetic keratinocyte differentiation [19].
affects the inflammatory response and can be a reason
Interleukin-22 as a therapeutic treatment for diabetic foot ul-
for chronic inflammation related to diabetes.
cers has demonstrated to be more effective than PDGF and
Subsequently, the treatment of wounds with mesenchymal
VEGF treatment options. It is because the Interleukin-22 in-
stem cells decreases inflammation and accelerates wound
duces genes are included in the reepithelialization, innate host
healing [28]. The expression of miR-146a depends on an
defense mechanism and the modeling of the tissues, which are
extracellular signal and the treatment results in increased
derived from the wounded skin [20].
expression of miR-146a in the surrounding tissue [29].
Furthermore, miRNAs play a crucial role in the onset
3.6 Role of IGFs and the development of diabetes by directly affecting pan-
creatic β-cell function [30]. The critical factor that affects
Insulin like growth factors (IGFs) is anti-catabolic and pro- the inflammatory response in wounds is the micro RNA
anabolic agents that act on a multitude of cell types [21]. IGF known as the miR-146a. This small non-coding RNA
is a complex of two peptides, namely; the IGF-1 and IGF-2. serves as a negative feedback regulator of IRAK1 and
IGF-1 is a cytokine which is a facilitator and moderator of the TRAF6 expression. IRAK1 and TRAF6 are elements of
growth hormone [22]. It is produced by the liver when the intracellular signal conducting cascade that is connected
growth hormone is released in the bloodstream. IGF-1 plays with transmembrane receptors, including the receptor acti-
an important role in growth, as it encourages growth promo- vator of nuclear factor kappa-B-ligand (RANKL/RANK).
tion of every cell of the body [23]. It bonds to the insulin-like
growth factor 1 receptor (IGF1R) in the cells and commences 3.9 Role of SDF-1-alpha
the process of intracellular signaling. It activates the Protein
Kinase B (PKB) that results in cell proliferation, apoptosis, Stromal cell Derived Factor 1 alpha (SDF-1α) is a highly
and glucose metabolism [24]. In addition, it also leads to cell conserved chemokine that plays a crucial and multifaceted
migration and transcription. In patients with diabetic foot ul- role in the wound healing process in both normal and diabetic
cers, IGF-1 participates in cell granulation during wound environments. The level of SDF-1α in the wound plays a key
healing. The expression of IGF-1 is decreased in diabetic pa- role in the response of wound healing. Inhibition of SDF-1α
tients, which results in anomalies in cell granulation. IGF-I results in a substantial decrease in the rate of diabetic wound
inhibits apoptosis pathways, attenuates pro- and anti- healing, and also leads to decreased improvement in the early
inflammatory cytokine production. In addition, it is mitogenic phase of non-diabetic wound healing. SDF-1α inhibition also
Rev Endocr Metab Disord

results in fewer small-caliber vessels, less granulation tissue for the formation of a vascular system in embryos and
formation, and amplified pro-inflammatory gene expression tumors [12]. The hypoxia in wounds also promotes the
(IL-6 and MIP-2) in the diabetic wounds [31]. Modifications migration of keratinocytes and the restoration of the ep-
in the wound level of SDF-1α impairs healing by decreasing ithelium. HIF-1α stability, balance, and activation are
angiogenesis and cellular migration and results in increased negatively affected in diabetic patients suffering from
production of inflammatory cytokines and inflammation. hyperglycemia. Hyperglycemia leads to suppression of
Diminished EPC function and recruitment has been in- the expression of HIF-1 target genes that are vital for
volved in the delay of diabetic wound healing. In addition, wound healing in patients with diabetic foot ulcers.
diabetic wounds present a lower migration of EPCs to circu- Substantially reduced levels of Hif-1α is observed in
lation, which comprises of low-intensity neoangiogenesis. patients with diabetic foot ulcers [34] and can be one
Subsequently, SDF-1a promotes these EPCs to the site of of the major reasons for poor blood vessel formation in
injury, where they participate in neovasculogenesis. SDF-1α the diabetic foot.
has been shown to promote the proliferation and migration of
endothelial cells. Similarly, it also increases the growth of
granulation tissue and progenitor and endothelial cells. In ad- 3.12 Role of RANKL
dition, the administration of SDF-1 increases blood flow and
perfusion through the recruitment of endothelial progenitor Receptor activator of nuclear factor kappa-Β ligand
cells (EPCs). SDF-1α also regulates the migration of EPCs (RANKL) is a type II membrane protein. It is also known
as well as a leukocyte [32]. as tumor necrosis factor ligand superfamily member 11
(TNFSF11). RANKL plays an imperative role in the con-
3.10 Role of c-myc trol of bone regeneration and remodeling. In addition,
RANKL is an apoptosis regulator gene and a binding
Among many pathogenic markers that are associated with partner of osteoprotegerin (OPG). In addition, it is also a
delayed wound healing, c-myc plays a pivotal role. Its expres- ligand for the receptor RANK and further controls cell
sion is activated by B-catenin, which is implicated in the in- proliferation by modifying protein levels of Id4, Id2,
hibition of keratinocyte migration, and in the response of the and cyclin D1. The importance of RANKL in tissue
epidermal growth factor EGF. The activation of c-myc in growth, and more specifically in bone growth cannot be
chronic wounds is related to the role of its activator, B-catenin, overstated. It is also implicated in the control of the im-
in the inhibition of wound healing. Inhibitors of wound mune functions within the body [35].
healing such as glucocorticoids (GC) induce c-myc expres-
sion. The stabilization of B-catenin inhibits keratinocyte mi-
gration and wound healing. In addition, B-catenin also plays 3.13 Role of TNFa
an imperative role in signaling of GC and repression of the
keratin genes [33]. Tumor necrosis factor alpha (TNFα) or cachexin/
cachectin is a cell signaling protein that is implicated in
3.11 Role of HIF-1 systemic inflammation and is one amongst many cyto-
kines that are part of the acute phase reaction. It is pri-
Apart from this function, it was found that IGF-1 is marily produced by activated macrophages and plays an
critical in the regulation of the synthesis of hypoxia- essential role in the regulation of immune cells. It also
inducible factors (HIFs) protein during wound healing induces insulin resistance by promoting serine phosphor-
in patients enduring diabetes. The diminished level of ylation of insulin receptor substrate-1 (IRS-1) that
IGF is directly connected to the low levels of Hif-1 pro- weakens insulin signaling [36]. TNFα is linked with the
tein. Hif-1 is an angiogenesis-promoting factor and it destruction of connective tissue. This is due to the release
controls the expression of many downstream factors that of lytic enzymes that are manufactured by both resident
are implicated in angiogenesis. HIFs are transcription and inflammatory cells. The deletion or inhibition of
factors that respond to decreases in available oxygen in TNFα plays an important part in the tissue repair process.
the cellular environment. It also plays a fundamental role Control of the TNFα expression has shown to significantly
in the regulation of all the critical processes involved in assist in wound healing in diabetic patients. TNFα blocker has
tissue repair. The HIF-1 signaling cascade mediates the shown to reduce apoptosis of the bone-lining cells of a diabet-
effects of hypoxia, which is defined as the state of low ic wound and augment the formation of bone, during the dia-
oxygen concentration on the cell. In addition, HIFs keep betic wound healing process. On the other hand, the develop-
cells from differentiating. Apart from this, HIF-1 pro- ment of duodenal ulcer and gastric cancer is linked to poly-
motes the formation of blood vessels and is important morphism of cytokine genes such as TNFα [37].
 Rev Endocr Metab Disord

3.14 Role of Cathepsin-D 3.16 Role of HSP

Cathepsin D is an aspartic endo-protease that is ubiquitous- Heat shock proteins (HSP) are a family of proteins that are
ly distributed in lysosomes and is implicated in maintain- produced by cells in response to exposure to stressful condi-
ing body metabolism and homeostasis. The primary func- tions. They are defined in relation to heat shock, but also have
tion of cathepsin D is to degrade proteins and activate a vital role and are also expressed during other stresses includ-
precursors of bioactive proteins in pre-lysosomal compart- ing exposure to cold, UV light, and during wound healing or
ments. It also plays a crucial role in the activation and tissue remodeling. HSPs stimulate and enhance wound
degradation of polypeptide hormones and growth factors, healing by the employment of dermal fibroblasts in the site
activation of enzymatic precursors and metabolic degrada- of the injury [43]. This process leads to the homeostasis of
tion of intracellular proteins. Subsequently, it assists in the protein. Heat shock protein 27 (HSP27) is a small heat shock
processing of enzyme activators and inhibitors and brain protein that is present in many cells in the human body. The
antigen processing and regulation of programmed cell primary function of these cells is the differentiation of tissue,
death. However, significantly high levels of cathepsin D cell development regulation, thermotolerance and inhibition
have been found in people enduring type 2 diabetes and of apoptosis. There is a high level of this protein in patients
can also lead to cardiovascular complications and dysfunc- suffering from cancer and individuals enduring muscular and
tion in diabetics. This is due to cathepsin D’s involvement neurodegenerative diseases. The HSP27 expression is also
in the apoptosis of the macrophage cells that are responsi- high in patients with diabetic microvascular and
ble for the instability of plaque. The exact mechanism as- macrovascular problems and is associated with diabetic pe-
sociated with high levels of cathepsin D in diabetic and ripheral neuropathy [44]. The Hsp70 protein is especially sus-
non-diabetic individuals still remains uncertain [38]. In ad- ceptible to toxic materials like copper, mercury, cadmium, and
dition, in non-diabetic individuals, cathepsin D has been arsenic. HSP70 safeguards cells from oxidative and thermal
revealed to be high along with the diagnosis of insulin stress. In the instance when partial unfolding of the cells hap-
resistance [39]. Moreover, cathepsin D mucosal levels pens, Hsp70 stops the partially unfolded proteins from aggre-
have found to be high in Helicobacter pylori-infected pa- gating by binding to hydrophobic residues that have been
tients, who suffered from either duodenal or gastric peptic exposed by stress. There are higher serum levels of HSP70
ulcer [40]. found in patients with diabetes [45]. This is due to the high
oxidative stress of patients with diabetes and HSP70 is known
3.15 Role of MMP to act as a shield against oxidative states. HSP47 has also been
found in high levels in animals, soon after an injury and in
Matrix metalloproteinases (MMPs) are calcium-dependent patients with diabetic foot ulcers [46]. The expression of
zinc-containing endopeptidases. MMPs play a key role in HSP70 and HSP47 in rats that have been examined with gas-
cell behaviors and are involved in various functions such tric ulcer have been shown to alter during the healing stage of
as cell proliferation, migration, differentiation, angiogene- the ulcer. High levels of HSP70 are implicated in quick ulcer
sis, adhesion and dispersion, apoptosis, and host defense. healing and conversely, accelerated levels of HSP47 are found
In optimal levels, MMPs are ideal for wound healing. They to delay the healing of gastric ulcer [47].
are involved in the elimination of the damaged extracellu-
lar matrix in the inflammatory stage of the wound.
Furthermore, in the proliferation phase, they play a para- 4 Healing of ulcer
mount part in cell migration and the breakdown of the
capillary membrane intended for angiogenesis. Ulcer healing is heavily influenced by the quality of the care
Consequently, MMPs hugely assist in the tissue remodel- provided and the adherence to it by the patients. Similarly,
ing stage of wound healing [41]. High levels of MMPs play physicians play an important role in providing state-of-the-
a negative role in tissue repair and consequently in the poor art care, including education and appropriate ulcer offloading,
wound healing process of diabetic foot ulcer. They are also and also monitor the adherence to it. However, chances of
implicated in the development of diabetic nephropathy, infection and abrasions are likely in cases where there are
leading to glomerular hypertrophy and extracellular matrix accidental injuries and when hyperglycemia cannot be con-
deposition. There has been a link between MMPs and hem- trolled for varied reasons. The four stages of wound healing
orrhoidal thrombosis. The regulation of matrix metallopro- generally are hemostasis, inflammation, proliferation and mat-
teinases is directly related to Neutrophil gelatinase- uration or remodeling. The hemostasis process is the body’s
associated lipocalin (NGAL). High levels of both MMPs defense mechanism to stop bleeding in the event of an injury
and NGAL are found in patients suffering from or a wound [48]. It starts as soon as there is bleeding and the
thrombosed hemorrhoids [42]. blood vessels contract to control the flow of blood. The
Rev Endocr Metab Disord

platelets bind together to repair and seal the broken blood change in any of the factors can detrimentally affect the
vessel. Consequently, the platelet plug is strengthened with wound healing. The same is observed in the diabetic patients
threads of fibrin that act as binding agents and form a clot. as they are negatively influenced by the exogenous factors,
The second phase of wound healing is the inflammatory stage due to which the wound fails to heal in an appropriate manner,
in which there the wound becomes swollen due to the blood leading to the formation of a chronic wound. This affects the
vessels undergoing transudation. The engorgement facilitates epigenetics which complicates the wound further. The remod-
wound healing by moving the repair cells to the wound area. eling phase begins after the proliferative phase, following the
The symptoms associated with this stage are pain, swelling, maturity of the vascular and regression, taking up to 6–
redness, and heat. During this stage, many enzymes, white 24 months from the time injury took place.
blood cells, nutrients, and growth factors work earnestly to
remove the bacteria, pathogens and damaged cells from the
wound. The third phase is the proliferation stage in which the 5 Acute and chronic wound healing
wound starts to rebuild. The new tissue is generally made of mechanism
extracellular matrix and collagen [49]. As the new tissues are
built the wound contracts with the help of myofibroblasts. Acute wounds progress through the normal stages of wound
Finally, the epithelialization process occurs in which the epi- healing and show definite signs of healing within 4 weeks. On
thelial cells resurface. The final phase of wound healing is the the contrary, chronic wounds do not progress normally
maturation or remodeling stage in which collage remodeling through the stages of healing and more often get stalled in
occurs. In this phase, the collagen that was roughly organized one phase. Consequently, chronic wounds do not show evi-
in the proliferative stage is neatly structured and bond closer dence of healing within 4 weeks. Chronic wounds occur in
together [50]. individuals enduring metabolic deficiencies, diabetes, infec-
It can be observed in Fig. 2 that the healing of the wound tion, and venous disease. Wounds that do not show signs of
cascade involves various phases, which can form a chronic healing after 3 months are categorized as chronic wounds.
nonhealing wound [50]. Since the healing of the wound re- Chronic wounds tend to have a prolonged inflammatory
quires the effort of mediators i.e. growth factors, inflammatory phase. Furthermore, in chronic wounds the balance between
cells such as cytokines as well as proteases; therefore, the the production and the degradation of the molecules is not

Fig. 2 Pathophysiology of cytokines, proteolysis and epigenetics of wound healing in diabetes (adopted from Thiruvoth et al. 2015 [50])
 Rev Endocr Metab Disord

maintained, leading to degradation [51]. As compared to the and minerals essential in bone regeneration. A critical com-
linear progression of the acute wound healing in healthy indi- ponent in bone healing in a non-diabetic individual is the
viduals, the chronic wound healing in diabetic patients is hin- timely appearance of blood vessels in the fracture callus.
dered in variant phases and synchronous progression does not Angiogenesis, which is defined as the formation of new
occur considering its association with the neuropathy, microan- blood vessels from pre-existing ones, is enthused after the
giopathy, and impaired immune function [52]. Other factors fracture by the production of many angiogenic growth fac-
associated with chronic wounds are ischemia, immune suppres- tors. However, in the presence of high blood sugar, the bone
sion, and neoplasias. In contrast with acute wounds, chronic tissue experiences modifications in composition, quality
wounds have high levels of MMPs and proteolytic enzymes and biomechanical properties, which can consequently lead
[53]. Apart from this, there are low levels of the keratinocyte to impairment and delay in bone fracture healing [56]. In
and platelet-derived growth factors. Inadequate GFs can result addition, there is a decrease in the protein expression levels
in the formation of chronic wounds. Chronic wounds such as of several growth factors that are closely associated with
venous ulcers and diabetic wounds are triggered by the failure osseous healing such as PDGF, IGF-1, VEFG, and TGF-
of keratinocytes to epithelialize the diabetic wound [54]. In B1 (Fig. 4). Predominantly for the VEGF, substantial mod-
addition, they may be caused by the failure of the production ifications have been reported in its expression levels during
of the appropriate amount of ECM proteins [55] (Fig. 3). the fracture healing process [57]. Diabetes negatively im-
pacts fracture repair by means of resorption of cartilage and
increased osteoclast genesis during the transition from car-
6 Fractured bone healing tilage to bone in the repair process. The premature loss of
cartilage leads to a reduction in callus size and contributes
Blood supply is critical for the development and proper to the decreased bone formation and mechanical strength
functionality of bone tissue, providing oxygen, nutrients, which is observed in diabetic fracture healing [58].

Fig. 3 Difference in healing of the acute and chronic diabetic wound (adopted from Johnson et al. 2018 [63])
Rev Endocr Metab Disord

Fig. 4 Overview of the

mechanism involved that convert
ulcer into an infection in diabetic
patients

7 Genetics of diabetic foot ulcer healing Synthase 1 Adaptor Protein) is a protein-coding gene
which binds to neuronal nitric oxide synthase (nNOS)
Genetics of DFU healing is comprised of familial clus- and that further binds to monomeric protein Dexras 1.
tering, metabolic memory, epigenetics, and single nucle- It has been found that NOS1AP deviation is connected
otide polymorphism (SNPs). SNPs plays a critical role in with the mobilization of stem-progenitor cell concentra-
the fluctuation of these growth factors and cytokines in tion (SPC) and impaired wound healing in patients with
DFUs. It is because SNP is associated with various ulcer Diabetic Foot Ulcers. Amputation of the lower extremity
grader, infection, and amputation which occur in the di- is linked to NOS1AP gene variation [61].
abetic foot ulcer [59]. The importance of epigenetic
mechanisms in diabetes and the complex interplay be-
tween genes and the environment cannot be overstated. 8 Conclusion
Epigenetic changes are very varied and include methyla-
tion of cytosine in DNA, histone post-translational mod- In conclusion, much progress has been made in understanding
ifications, mitochondrial inheritance, microRNA expres- the pathogenesis and management of diabetic foot problems in
sion and non-coding RNAs [60]. Deregulation of these recent years. The role of the human growth factors and cyto-
epigenetic mechanisms occurs due to many factors that kines have been crucial in the past few decades. In addition,
are connected to the diagnosis of the complications of the molecular steps involved in the healing of ulcer in the
diabetes. These include oxidant stress, growth factors, diabetic patient have been advanced to show contributions in
hyperglycemia, and many inflammatory factors. In addi- the management of diabetic foot problems. The role of PDGF,
tion, this leads to an alteration in the expression of path- KGF, FGF, VEGF, Interleukins Role of IGF (Insulin-like
ological genes in target cells such as endothelial, retinal growth factors), TGF-β-1 and miR-146 has also substantiated
and cardiac cells and vascular smooth muscle without
contributions in diabetic wound healing has been analyzed.
fluctuations and modifications in the underlying genomic
Subsequently, it has been concluded that the regulation and
DNA sequence [60].
dysregulation of epigenetic mechanisms occurs due to factors
DNA methylation is a process of inactivation of one
connected to the diagnosis of the complications of diabetes.
gene allele, as the basis of genetic imprinting. It further
Additionally, the study suggests that a quantitative approach
depends on the methylation pattern inherited from one of
may also be adopted by the future studies for assessing the role
the parents. In consequence, only one copy of the gene is
each of these growth factors imposes on the diabetic foot
active. In spite of the achievement of the glycemic con-
ulcer. This would help in revealing new insights concerning
trol, a crucial mechanism underlying the phenomenon of
the treatment of diabetic foot ulcer.
‘metabolic memory’ and sustained vascular dysfunction
is the perseverance of the modifications in the expression Acknowledgments The author is very thankful to all the associated per-
of pathological genes [60]. NOS1AP (Nitric Oxide sonnel in any reference that contributed in/for the purpose of this research.
 Rev Endocr Metab Disord

Compliance with ethical standards 16. Gardner JC, Wu H, Noel JG. Keratinocyte growth factor supports
pulmonary innate immune defense through the maintenance of al-
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Conflict of interest The authors declare that they have no conflict of
Phys Lung Cell Mol Phys. 2016;310:L868–79. https://doi.org/10.
interest.
1152/ajplung.00363.2015.
17. Bao P, Kodra A, Tomic-Canic M, Golinko MS, Ehrlich HP, Brem
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