The Efficacy of Human Amniotic Membrane Mesenchymal Stem

Cells (hAMMSC) Plus Vitamin C for Treating Chronic Plantar Ulcer

in Leprosy Patient: A Case Report

Riyana Noor Oktaviyanti,

Rahmadewi,

Medhi Denisa Alinda

, Bagus Haryo Kusumaputra

, Linda

Astari

, M. Yulianto Listiawan, Indropo Agusni

, Fedik A. Rantam

2,3

and Cita Rosita Sigit

Prakoeswa

Departement of Dermatology Venereology, Faculty of Medicine Universitas Airlangga, Dr Soetomo General

Hospital, Surabaya, Indonesia

Stem Cell Research and Development Center, Universitas Airlangga, Surabaya, Indonesia.

Virology and Immunology Laboratory, Department of Microbiology, Faculty of Veterinary Medicine, Universitas

Airlangga, Surabaya, Indonesia

Keywords: amniotic membrane stem cells, vitamin C, plantar ulcer, leprosy/MH

Abstract: Chronic plantar ulcer in Leprosy is a still a problem in term of patient’s medical and social aspect.

Amniotic membrane stem cell (AMSC) conditioned medium provide growth factors and sitokin for the

chronic ulcer’s healing. Vitamin C as antioxidant, anti inflamatory, dan collagen synthesis can be useful for

wound healing.

1 INTRODUCTION

Chronic plantar ulcers in Morbus Hansen (MH)

including level 2 defects, are the most common

cause of disability in MH patients. The prevalence of

level 2 deficiency in MH patients in Southeast Asia

increased from 2010 to 2011 by 2.5%. In Indonesia,

MH patients with disability level 2 also increased

during the year 2011-2012 by 10.11% (World

Health organization, 2012; Metro Tempo Co., 2013).

Approximately 30% of patients with Leprosy have

peripheral nerve damage, and 10-20% of them have

neuropathic ulcers due to peripheral nerve

damage. Chronic ulcers are a serious medical and

social problem. Patients experience decreased

quality of life, so wound healing management

continues to be investigated to deal with chronic

ulcers (Halim and Menald, 2010; Bauman, Girling,

and Brand, 1963). In chronic ulcers there is a

decrease in growth factors such as platelet derived

growth factor (PDGF) and growth factor

transformation (TGF) -β required in the healing

process, there is a high level of reactive oxygen

species (ROS), which can damage cells and collagen

degradation (Diegelmann and Evan, 2004).

Nowadays start developed therapy using

metabolite product from stem cell without the stem

cell. The use of this metabolite product is easier and

safer because it is aseluler. The AMSC metabolite

product was obtained at culture from AMSC, which

in this metabolite product contained several

cytokines and growth factors required for wound

healing (Lindenmair et al., 2012; Ennis, Sui, and

Bartholomew, 2013).

Vitamin C known as antioxidants and play role

in collagen synthesis. These functions are believed

to also be useful in wound healing. As an

antioxidant vitamin C neutralizing ROS that we

could found in chronic ulcers. Vitamin C also

directly stimulates collagen synthesis. One

derivative of vitamin C that is stable is sodium

ascorbyl phosphate (SAP) (Telang, 2013).

2 CASE

38- year-old female patient, working as a housewife

came with chief complaint ulcer at her right foot

since 1 years ago, painless and no itchy sensation. At

first the ulcer is small, then became bigger and

deeper by the time. Patients have been frequently

treated since the last 8 months for her complaints,

Oktaviyanti, R., Rahmadewi, ., Alinda, M., Kusumaputra, B., Astari, L., Listiawan, M., Agusni, I., Rantam, F. and Prakoeswa, C.

The Efﬁcacy of Human Amniotic Membrane Mesenchymal Stem Cells (hAMMSC) Plus Vitamin C for Treating Chronic Plantar Ulcer in Leprosy Patient: A Case Report.

DOI: 10.5220/0008159104330436

In Proceedings of the 23rd Regional Conference of Dermatology (RCD 2018), pages 433-436

ISBN: 978-989-758-494-7

433

she got treatment for treating wounds with sterile

normal saline, antibiotics ointments and framycetin

gauze dressing (FGD) but no improvement.

The patient was suffering from borderline

leprosy since 3 years ago. She had already got

multibacillary multi-drug therapy for 12 months and

had finished the treatment 1 year ago. The result of

microbiology Mycobacterium leprosy examination

was bacterial index (BI) 0 and morphological index

(MI) was negative.

The initial treatment for the ulcer was sterile

normal saline and surgical debridement to remove

necrotic tissue, callus, and debris. After obtaining a

clean ulcer, wound area and wound depth

measurements were performed. Then the ulcer was

given FGD and sterile gauze above the FGD. On

subsequent visit, the ulcers begin to be given topical

hAMMSC-CM + Vit C gel and covered with

transparent film dressings. Application of gel was

done every 3 days, and weekly evaluation included

measurement of the size and the depth of the ulcer

was done. Initial measurements of the ulcer was 2 x

2 x 0.4 cm. Patient received hAMMSC-CM +

vitamin C gel for 7 weeks. After the therapy with

hAMMSC-CM + Vit C gel for 7 weeks, the ulcer

healed compeletely.

3 DISCUSSION

Since the early 20th century, amniotic membranes

have been used for the treatment of widespread

injuries, burns, chronic ulcers, deep ulcers, and

surgical wounds that are difficult to heal

completely. Studies on the human amniotic

membrane mesenchymal stem cells (hAMMSC) for

the repair and regeneration of cells showed good

results. The growth factors and cytokines can be

found in the tissue medium of stem cells in in

vitro conditions through its metabolite product so it

can be utilized as a useful modality in the process of

cell regeneration (Bauman, Girling, and Brand,

1963; Diegelmann and Evan, 2004).

The previous research has proved that injuries

that are difficult to heal in humans have high levels

of oxidative stress. Wounds or chronic ulcers often

show the increasing levels of reactive oxygen

species (ROS) or free radicals that can delay wound

healing process, inhibit the formation of granulation

tissue and epithelialization. Free radicals are formed

in response to tissue damage which then inhibits the

recovery process by attacking DNA, membranes,

proteins, and lipids from cells. Antioxidants are

believed to repair wounds by reducing the damage

caused by free radicals released by neutrophils in the

inflammatory phase of the wound healing process

Ennis, Sui, and Bartholomew, 2013; Telang, 2013).

Plantar ulcers in leprosy are neuropathic ulcers,

occurring due to prior nerve damage or sequelae.

Chronic ulceration results from one or more

extinctions of the wound healing phase (WHO,

2012). In a chronic wound, one may detect a

prolonged inflammatory response, elevated protease

activity and decreased growth factors. These

findings may account for the delayed wound healing

process. The prolonged inflammatory response may

be caused by infection or just inflammation. The

FGD is an antibiotic wound dressing that works in

the inflammatory phase of wound healing by treating

the infection and contra-acting the colonisation. It is

not effective in an inflammatory phase of wound

healing that is not caused by infection. It is also not

effective in the proliferative phase of wound healing

(Halim and Menald, 2010; Metro Tempo Co., 2013).

Prakoeswa et al (2018), study analytical

experimental approach comparing the topical

hAMMSC-CM and the framycetin gauze dressing

(FGD) applied every 3 days up to 8 weeks on the

healing of CPUL. Ulcer healing in the hAMMSC-

CM group was significantly better than that in the

FGD group with significant clinical and statistical

differences (p < 0.005 and p< 0.005).

The hAMMSCs contains many cytokines and

growth factors, which may be effective in the

inflammatory and the proliferation phase of the

wound healing. In the inflammatory phase of wound

healing, the pro-inflammatory cytokines in

hAMMSCs may influence the infection and

colonisation via its antimicrobial effect and the anti-

inflammatory cytokines in hAMMSCs will diminish

the inflammation (immunomodulatory effect). In the

proliferation phase of the wound healing, the growth

factors in hAMMSCs willstimulate proliferation and

migration of cells, induce angiogenesis, and

stimulate the formation of tissue granulation and

epithelialization (Bauman, Girling, and Brand, 1963;

Diegelmann and Evan, 2004).

RCD 2018 - The 23rd Regional Conference of Dermatology 2018

434

Figure 1: Healing progression. Ulcer treated hAMMSC-CM + Vit C healed completely at week 7

In the dermatology Vitamin C known as

antioxidants, and collagen synthesis. These functions

are believed be useful in wound healing. The

function of vitamin C as an antioxidant is beneficial

in neutralizing ROS present in chronic ulcers.

Vitamin C also directly stimulates collagen

synthesis. One derivative of vitamin C that is stable,

is sodium ascorbyl phosphate (SAP). This derivative

has the same function as vitamin C but has better

stability. The use of vitamin C and metabolite

products simultaneously is expected to accelerate

wound healing, with faster healing times that cost

less and the quality of life of patients increases

(Lindenmair et al., 2012; Ennis, Sui, and

Bartholomew, 2013).

Function of ascorbic acid as an antioxidant is

useful in inhibiting free radicals produced in the

inflammatory process (Moro, 1999; Telang, 2013).

Another study by Sarpoosh HR and colleagues

assessed the effectiveness of topical vitamin C in

necrotic tissue cause burns grade II. There were 30

patients with burns gr II divided into control groups

receiving sulfadiazine ointment and treatment group

receiving sulfadiazine ointment accompanied with

vitamin C. In the group of treatment the initial

necrotic tissue volume was 1.033 ± 0.182 and on day

14 the average volume was 1.233 ± 0.430, and in the

initial necrotic tissue volume control group was

1,000 ± 0,000 and at day 14 the average volume

became 1,700 ± 0.794. There was a significant

difference between the two groups, in the treatment

group, the mean difference of necrotic tissue volume

was less than the control group (Singh and Singh,

2012; Sarpooshi, Vaheb, Tabarayee, Sabzevar, and

Mortazavi, 2016)

4 CONCLUSIONS

In this case the function of vitamin C is SAP as

antioxidant, anti-inflammatory, antibacterial and

collagen synthesis can help wound healing where in

chronic injury disorders occur in the inflammatory

phase, and the proliferation phase. The combination

of PM-AMSC which contained several cytokines

and growth factor with vitamin C seemed to give

good results on the healing of chronic plantar ulcers

of leprosy, and in this case there were no side effects

in mixing PM-AMSC with vitamin C in chronic

leprosy ulcers.

The ulcer improvement within 7 weeks of

AMSC + vitamin C. There are several other factors

that also play a role in ulcer healing, age, type of

work and duration of ulcers may contribute to ulcer

healing.

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