Abstract
BACKGROUND:
The incidence of acute and chronic wounds has rapidly increased which treatment remains as health problem. Previously, we reported the healing effect of Vitamin K in experimental animal models. The aim of this study was to investigate the effects of topical Vitamin K on skin wound healing process in patients.
MATERIALS AND METHODS:
Sixty-three patients with indication for high-frequency electrocautery were enrolled in this randomized controlled trial. The patients were divided randomly into three groups. All the patients underwent high-frequency electrocautery treatment. Then, the patients in the A group received 1% Vitamin K cream, the patients in the B group received 1% phenytoin cream. Furthermore, the patients in the control group received Eucerin. The wound status (width and the time of recovery) and complications in the three groups were evaluated 2 weeks after procedure by a dermatologist.
RESULTS:
The effects produced by the topical Vitamin K showed a significant (P < 0.05) healing when compared with Eucerin group in parameters such as wound contraction and time to full recovery. Moreover, the healing time did not differ between phenytoin and Vitamin K groups (P = 0.16).
CONCLUSION:
A randomized, controlled trial suggests that topical application of Vitamin K significantly reduces healing time in patients.
Keywords: Phenytoin, skin, topical application, Vitamin K, wound healing
Introduction
The incidence of acute and chronic wounds has rapidly increased, with approximately 300 million chronic and 100 million traumatic wound injuries worldwide.[1] Moreover, cutaneous wound healing is an essential complicated physiological process consisting of the collaboration of many cell strains and their products.[2] Coagulation, epithelization, granulation, collegenation, and tissue remodeling are the phases of wound healing. Coagulation is the immediate response to initial injury. Thrombin generation leads to aggregation of a platelet and fibrin mass that fills and stabilizes the wound by preventing further blood loss. Fibroblasts line along the fibrin matrix and begin to form connective tissue, and the endothelial sprouts begin to revascularize the site, converting the wound into granulation tissue. During this, the epithelial cells migrate and proliferate across the surface of the wound, displacing the scab, until the wound is closed (re-epithelization)[3] Although some therapeutic strategies for acute and small area traumatic wounds have been proposed, these strategies are not effective in large area burns and infected and chronic wounds.[4]
Vitamin K is an essential cofactor for the carboxylation of specific glutamic acid residues to form γ-carboxyglutamic acid;[5,6] therefore, it has different roles in proliferation,[7] bone mineralization,[8] arterial calcification,[9] apoptosis, phagocytosis[10,11] growth control, chemotaxis,[12] and signal transduction.[13] Furthermore, Vitamin K also has redox properties and has been shown to alter cellular metabolism in a manner which might confer anti-inflammatory properties. Furthermore, Wang et al. reported that the blood coagulation system can be a tool to coordinate angiogenesis and vascular development, especially in skin wound healing process.[14]
In view of the abovementioned actions, it was thought worthwhile to investigate the action of topical Vitamin K in wound healing. Hence, the aim of this study was to evaluate the healing effect of Vitamin K in patients with indication for high-frequency electrocautery.
Materials and Methods
Study design and target groups
We conducted a randomized, double-blind, placebo-controlled, parallel-group trial in Clinical Research Development Units of Ahvaz Imam Hospital, Southwest Iran, from November 2016 to May 2017. This trial was prospectively registered with the Iranian Registry of Clinical Trials, number IRCT2016030226881N1. This study received approval from the Ethics Committee of Ahvaz University of Medical Sciences (IR.AJUMS.REC.1395.55), and all participants gave written informed consent. Patients who referred to our clinic (Dermatology Clinic of Ahvaz Imam Hospital) with indication for high-frequency electrocautery treatment and lack of using any treatment during 2 months before were eligible for recruitment. Exclusion criteria were the sensitivity to Vitamin K, phenytoin cream, Eucerin, or dissatisfaction to continue participation in the study.
Vitamin K1 (phylloquinone) was purchased from Sigma-Aldrich Co. (St. Louis, MO, USA). It was mixed with Eucerin for preparing 1% cream (w/w). Phenytoin (positive control) purchased from Darupakhsh Co., Tehran, Iran, and incorporated in Eucerin for preparing 1% cream (w/w). The doses of phenytoin and Vitamin K for topical administration were selected based on our previous report.[15]
Study population and intervention
The study flowchart is shown in Figure 1. Sixty-three participants with skin wound who had been diagnosed by a dermatologist were included in the study. The participants were simple-randomized in three groups using a block randomization method. Double blinding was maintained by the use of identical Vitamin K, phenytoin, or Eucerin creams. Fifty-four patients completed the study, 16 from Vitamin K group, 19 from phenytoin group, and 19 from control group.
Figure 1.
Study flowchart (CONSORT format)
All the participants underwent high-frequency electrocautery treatment. Then, the participants in the A group received 1% Vitamin K cream twice a day, the patients in the B group received 1% phenytoin cream twice daily. The patients in the control group received Eucerin twice a day. All the patients visited on the 4th, 7th, and 14th day. In every visit, the wound shaped on transparent sheet and then measures the surface area of the wound by the graph paper with labeled scale (wound status). Moreover, complications in the groups were evaluated 2 weeks after procedure by a dermatologist.
Data analysis
Statistical analysis was by intention-to-treat without interim analysis. All data are given as the mean ± standard error of the mean. The statistical analyses were performed by one-way analysis of variance (ANOVA), followed by Tukey's post hoc test unless otherwise stated. A two-way ANOVA, followed by Bonferroni test, was carried out for the time-course effect of Vitamin K. Data analysis was performed using the Prism 5.01 (San Diego, CA, USA) statistical package program. P < 0.05 was considered to be statistically significant.
Results
Baseline characteristics of patients
Demographic features are shown in Table 1. A total of nine patients were dropped out, and finally, 54 patients completed the study. Before intervention, variables did not show a significant difference among the groups such as the area of the wound (P = 0.92), except type of lesion. Accordingly, skin tags were significantly more in Vitamin K group (57.14%), while the nevus was more in other two groups (61.9% in phenytoin group and 47.61% in control group) (P = 0.001). Furthermore, based on wound site, the neck was significantly more in Vitamin K group (42.85%), while the face was more in other two groups (71.42% in both groups) (P = 0.02).
Table 1.
Baseline demographic characteristics
| Variables | Group |
P | ||
|---|---|---|---|---|
| Vitamin K (n=16), n (%) | Phenytoin (n=19), n (%) | Control (n=19), n (%) | ||
| Age (year) | 37.1±8.6 | 36±12.6 | 28.9±11.5 | 0.03 |
| Sex (male) | 9 (42.9) | 8 (38.1) | 5 (23.8) | 0.40 |
| Type of lesion | ||||
| Cherry angioma | 1 (4.76) | 0 | 0 | 0.001 |
| Skin tags | 12 (57.14) | 5 (23.8) | 3 (14.28) | |
| Nevus | 7 (33.33) | 13 (61.9) | 10 (47.61) | |
| Wart | 0 | 3 (14.28) | 3 (14.28) | |
| Syringoma | 0 | 0 | 1 (4.76) | |
| Pyogenic granuloma | 0 | 0 | 1 (4.76) | |
| Xanthelasma | 0 | 0 | 1 (4.76) | |
| Lentigo | 0 | 0 | 1 (4.76) | |
| Milia | 0 | 0 | 1 (4.76) | |
| The wound site | ||||
| Trunk | 3 (14.28) | 0 | 1 (4.76) | 0.02 |
| Neck | 9 (42.85) | 5 (23.8) | 3 (14.28) | |
| Face | 7 (33.33) | 15 (71.42) | 15 (71.42) | |
| Axillary | 2 (9.52) | 0 | 0 | |
| Lip | 0 | 0 | 1 (4.76) | |
| Hand | 0 | 1 (4.76) | 1 (4.76) | |
Assessment of wound healing as per wound area
The decrease in wound area on day 4 and day 7 was significant in the intervention group [Figure 2]. Results showed that application of Vitamin K improved wound healing at all times beginning on the 4rd day with statistical significance achieved from the 7th day as compared with the Eucerin-treated group (F (2, 169) = 6.86, P < 0.01).
Figure 2.
Effect of topical application of Vitamin K on wound healing (wound contraction). Time course of healing effect of Vitamin K on wound size. Vertical lines indicate the mean ± standard error of the mean, *P< 0.05 compared with Eucerin-treated group
Assessment of healing time
As shown in Figure 3, the mean healing time was 12.4 ± 3.69 mm2, 10.6 ± 3.6 mm2, and 10.05 ± 3.2 mm2 in the Eucerin, Vitamin K groups, and phenytoin, respectively. Results revealed that the slight reduction in healing time was not significant (F (2, 51) = 0.49, P = 0.6).
Figure 3.
Effect of topical application of Vitamin K on healing time. Vertical lines indicate the mean ± standard error of the mean
Discussion
Accelerating skin wound healing is a very important issue for physicians and patients; therefore, researchers evaluated various materials on wound healing, and beneficial effects of some of these materials have proved during the investigations. The present study for the first time demonstrated that Vitamin K may promote wound healing activity in patients.
Vitamin K, an essential micronutrient present in low concentration in the blood,[16] is required for the γ-carboxylation of specific glutamyl residues in several hepatic and extra-hepatic proteins.[17] In the present study, we observed that topical application of Vitamin K significantly increases the rate of wound contraction. At the previous work, we reported that topical Vitamin K may promote wound healing activity, probably due to its ability to significantly increase the rate of wound contraction, enhancement of epithelialization period, formation of fibroblasts cells, collagen fibers and blood vessels, and increment in hydroxyproline content in experimental models.[15] In this regard, Sharaev et al. revealed that in rats with secondary avitaminosis K, the collagen content in the skin was reduced and the content of free hydroxyproline increased.[18] Moreover, it has been reported that the blood coagulation system can coordinate angiogenesis and wound healing.[14] Since Vitamin K has a well-known effect on γ-carboxylation of certain coagulation factors, the wound healing action of Vitamin K may be due to its effect on blood coagulation system.
Reactive oxygen species (ROS) plays a pivotal role in the pathogenesis and therapy of chronic wounds. Overproduction of ROS results in cytotoxicity and delayed wound healing. Therefore, elimination of ROS could be an important strategy in healing of chronic wounds.[19] Some studies have shown that Vitamin K is considered as a potent antioxidant.[20] Therefore, Vitamin K could also improve the wound healing based on its antioxidant properties. However, further studies to elucidate the exact mechanism of action of Vitamin K in wound healing will be required for confirmation.
Conclusions
The current study demonstrated the beneficial effects of Vitamin K in wound healing process, which could be prescribed as a treatment in addition to standard therapy and lead to better control of wound healing process in the short term. Therefore, Vitamin K can be used as a supplemental drug along with other proven treatment in patients with acute and chronic skin wounds.
Financial support and sponsorship
This study was supported financially by Ahvaz Jundishapur University of Medical Sciences. We gratefully acknowledge the CRDU of Ahvaz Imam Hospital. Funding sources have no involvement in the manuscript writing and in the decision to submit the manuscript for publication.
Conflicts of interest
There are no conflicts of interest.
Acknowledgments
This study is issued from the postgraduate thesis of Dr. Zahra Zeineli and was supported financially by Ahvaz Jundishapur University of Medical Sciences. We gratefully acknowledge the Clinical Research Development Units (CRDUs) of Ahvaz Imam Hospital. Funding sources have no involvement in the manuscript writing and in the decision to submit the manuscript for publication.
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