Background. Xuzhou Qufu Shengji Ointment (QFSJO) has been used in hospital and private medication for more than 30 years to treat the infective wounds after trauma. However, molecular investigation is lacking. This study used rats to explore the healing mechanism of QFSJO in promoting wound healing in human. Methods. One circular incision was individually generated on the back of 30 rats in three groups and challenged with 10⁸ CFU (0.3 mL) of Staphylococcus aureus. Then, one of the trauma groups was treated with QFSJO gauze, and the control group was covered with a piece of Vaseline gauze, while the western medicine group was treated with erythromycin in a similar way. The dressing change of all the groups was performed once a day for three weeks. The anti-inflammation and proangiogenesis of QFSJO were evaluated by enzyme-linked immunosorbent assay (ELISA). The levels of angiogenesis associated factors, vascular endothelial growth factor (VEGF) and basic fibroblast growth factor (b-FGF), hydroxyproline, and hemoglobin, were measured according to ELISA. The immunohistochemistry of CD31 and CD34 expression in granulation tissue was demonstrated and quantitatively analyzed for angiogenesis in granulation tissue in sites. Results. A faster wound healing ratio was observed in QFSJO-dressing-treated group than Vaseline- and erythrocin-treated groups. ELISA results showed that QFSJO promoted VEGF and b-FGF levels significantly in early stage of wound healing. QFSJO dressing group also showed an enhanced hydroxyproline and hemoglobin in granulation tissue. The expressions of CD31 and CD34 in granulation tissue of QFSJO group were higher than in the Vaseline and erythrocin groups. Conclusion. QFSJO improved the healing rate of the infective wounds by promoting the angiogenesis of granulation tissue and inhibiting the inflammation of the trauma tissue. Our finding suggests that QFSJO is able to help angiogenic capillary sprouts for collagen accumulates in the granulation tissue.
1. Introduction
The refractory infectious wound healing is a challenge in the surgical department, which is generally caused by accidental crush injury, bacterial contamination, exposure of callus after trauma, local defects of skin, and muscle necrosis. Tendons, nerves, and vascular injury can further enhance bacterial contamination [1]. Sometimes, the wound infection is triggered by lack of hygiene awareness or in patients who are long-term bedridden and with reduced immunity. According to the concept of traditional Chinese medicine (TCM), infectious wound belongs to “sore and ulcer” category and frequently need removal of slough to promote tissue regeneration through surgical methods. Xuzhou QFSJO has the functions of clearing heat (lower fever and reduce inflammation) and detoxifying (eliminating evil in body) and can be used in clinical treatment for crissum abscess, diabetic foot, and furuncle based on the herb ingredients and the TCM theory. The major contents of QFSJO are Astragalus membranaceus (AM), Lithospermum erythrorhizon (LE), commonly used as gromwell root’s (GR), Danggui (Angelica Sinensis, Radix), and others. AM is regarded as the major component in the formula because its tonifying function (Huang Qi in Chinese can be regarded as sufficient oxygen), which correct spleen deficiency, and then, it is used in diarrhea, fatigue, and loss of appetite as well as wound healing [2, 3]. The major components of AM are made of polysaccharides, flavonoids, and saponins. Because of their hydrophilic and hydrophobic functions, AM have been used for immunomodulating and as antioxidant, anti-inflammatory, and anticancer medications [4, 5]. Currently, AM has been applied in some western medication for restoring and strengthening the immune response, enhancing the number of white blood cells and neutrophils and increasing phagocytosis by macrophages to promote humoral and cellular immunity [6]. In recent studies, AM-based treatments have demonstrated significant amelioration in treatment of side effects induced by other orthodox drugs (e.g., cancer chemotherapeutics and some of immunosuppressants). GR, another important component of QFSJO, has been proved to protect against ultraviolet B-induced inflammatory in skin through apoptotic signals [4], increased ceramide production in atopic dermatitis [5], improve moisturization and barrier function, and promote wound healing. QFSJO, which originated from a private recipe with long history, has been affirmed the intangible cultural heritage of Jiangsu Province in 2016. From January 2014 to June 2020, Xuzhou QFSJO has been used to treat infective wound more than 200 clinical cases, and significant clinical effects were recorded. Compared with control cases, QFSJO promoted the growth of granulation tissue and the skin regeneration to accelerate the healing of infectious wound after trauma [1]. But, the mechanism of QFSJO remains unclear. Considering the pivotal role of QFSJO in treatment of infected wounds, in this study, we observed the efficacy of QFSJO in the treatment of infective full-thickness skin wound healing through a multicenter randomized double-blind controlled trial. In order to further clarify the mechanism of QFSJO in treating infected wounds, we collected the secretions of each group and determined the IL-6 and TNF-α by ELISA to detect the inflammation and anti-inflammatory effects. VEGF stimulates wound healing via multiple mechanisms including collagen deposition, angiogenesis and epithelization. We also detected the levels of VEGF and b-FGF in the tissue supernatant to clarify the angiogenesis effect of QFSJO. Furthermore, we measured the changes of hemoglobin and hydroxyproline in granulation tissue of the wound surface area. By using immunohistochemistry (IHC), the expression of CD31 and CD34 in the granulation tissue was evaluated for the angiogenesis. These approaches help us understand the molecular mechanism of QFSJO during the promotion of infective wound healing, which may further improve the effectiveness of QFSJO in dermatology and osteopathic medicine.
2. Materials and Methods
2.1. Preparation of Animals and Wound Healing Models
This study was approved by the ethnic committee of the Xuzhou Medical University (no. SYXK (Su) 2020–0048). Thirty Sprague Dawley (SD) male rats at week four (average weight 100 Gram) were anesthetized with 0.7% pentobarbital sodium via auricular veins (6 mL/Kg). Subsequently, their back hairs were shaved off (12 cm × 10 cm), and the wound sites were disinfected with povidone-iodine. A full-thickness circular excisional skin wound (20 mm in diameter and deep into the fascia) was created on the back of each SD rat with scissors and forceps. The wounds were covered with a circular gauze and infected with 0.3 mL Staphylococcus aureus (10⁸ CFU/mL). The rats were divided into three groups: the control group (Vaseline group), the treatment group (Xuzhou QFSJO), and the erythromycin group (western medicine group). During the study period, all the SD rats were kept in cages with free access to food and water. The day of wound operation was considered as day 0. The wounded areas were monitored by a camera (Fuji, S20 Pro, Japan) and measured on 3, 7, 14, and 21 postwound injury days. Wound healing rate [7] was calculated using the following formula: % of wound healing rate = (wound area on day 0–wound area on days)/wound area on day 0 × 100%. We followed the guidelines for Animal Care and Use of Xuzhou Medical University. One animal of each group was randomly selected and sacrificed at 3rd, 7th, 14th, and 21st postoperatory days, and the wound region was excised for subsequent detection the content of hydroxyproline and hemoglobin according to traditional and commercial protocols.
2.2. Composition and Processing Method of QFSJO
Xuzhou QFSJO (Jiangsu Medical Products Administration permit: Z04000706) was formulated and processed as follows: Astragalus (A. membranaceus) 12 g, Lithospermum 10 g, Angelica 12 g, blood charcoal 12 g, and raw gypsum 30 g were together pestled into 100-mesh sieve. Sesame oil (417 g) was boiled and added to the raw tortoise shells in a pot and fried until it became brown; then, the remaining sesame oil was added into the batch. Subsequently, sieved Angelica and Rehmannia glutinosa were added to the pot; frying was continued until deep fry to scorched. They were filtered (the residues were removed) and heated slightly to boiling point. Astragalus, comfrey, blood residual charcoal, calamine, and raw gypsum powder were added and they were stirred constantly and boiled slightly for 1.5 hours. The beeswax was melted in another pot until there was no foam, filtered into sesame oil pot with gauze, stirred about 10 minutes, and then left until the temperature dropped to 40°C. Stirring evenly was continued. It was packed and condensed and then stored at room temperature for use. QFSJO, erythromycin, and saline were provided by Preparation Laboratory of Xuzhou Traditional Chinese Hospital. Vaseline gauze was manufactured by Pharmaceutical Factory of Jiangsu Hospital of TCM (Jiangsu Pharmaceutical Approval Number 203201). The main active ingredients in the decoction are present in Table 1 and AM molecules in SMILES format (Table 2).
Active ingredient of AM [8]
Active ingredients of Angelica [9]
Active ingredients of Lithospermum [10]
Active ingredient of Rehmannia glutinosa Libosch [11]
Astragalus polysaccharides
Organic acids
Comfrey oil
Catalpol
Astragalus saponins
Polysaccharides
Shikonol
Rehmannia glutinosa polysaccharide
Astragalus flavone
Flavonoids
Alkannins