Published online Jul 15, 2026. doi: 10.4239/wjd.119741
Revised: April 1, 2026
Accepted: May 18, 2026
Published online: July 15, 2026
Processing time: 148 Days and 21.6 Hours
Diabetic ulcer is a prevalent chronic refractory wound and a severe complication of diabetes that drastically undermines patients’ quality of life and causes heavy economic burdens. Local dressing therapy is a core diabetic ulcer intervention, but existing functional hydrogel dressings are plagued by single-target action and insufficient antioxidant components and have become key bottlenecks in dressing research and development.
To develop a novel thermosensitive composite hydrogel dressing that overcomes the limitations of existing hydrogel dressings for effective diabetic ulcer mana
A thermosensitive composite hydrogel [PF/polyhexamethylene biguanide (PHMB)-nicotinamide mononucleotide (NMN)] was successfully fabricated by integrating NMN, which is a potent antioxidant, as the functional ingredient with Pluronic F127 and PHMB, an antibacterial agent. In this preclinical study, the effect of this hydrogel in the treatment of diabetic wounds was evaluated by both in vitro and in vivo experiments.
The PF/PHMB-NMN hydrogel possessed excellent sustained drug release, antibacterial and antioxidant pro
The NMN-PHMB-loaded Pluronic F127 thermosensitive composite hydrogel safely and effectively facilitates diabetic wound healing in a mouse model, offering a potential therapeutic strategy and promising a candidate dressing for further investigation in clinical diabetic foot ulcer management.
Core Tip: In this study, a thermosensitive Pluronic F127/polyhexamethylene biguanide composite hydrogel loaded with antioxidant nicotinamide mononucleotide was prepared, which showed sustained strong antibacterial and antioxidant properties and favorable biosafety. In vitro, hydrogel inhibited bacteria, and boosted cell migration and angiogenesis. In mouse models, it markedly accelerated diabetic ulcer healing via faster re-epithelialization, reduced inflammation, elevated collagen deposition and angiogenesis, as well as upregulating vascular endothelial growth factor and transforming growth factor-β1. This hydrogel is a safe, effective novel dressing for clinical diabetic ulcer treatment.
- Citation: Peng F, Li YY, Tang Y, Sun SX, Zhu YQ, Zhang XY, Zhu HZ. Nicotinamide mononucleotide-loaded thermosensitive hydrogel promotes diabetic wound healing via antibacterial and antioxidant synergy in a mouse model. World J Diabetes 2026; 17(7): 119741
- URL: https://www.wjgnet.com/1948-9358/full/v17/i7/119741.htm
- DOI: https://dx.doi.org/10.4239/wjd.119741
Diabetic ulcer, a severe chronic complication of diabetes, is increasing annually[1,2]. Due to metabolic disorders, impaired immunity and microcirculatory disturbances in diabetic patients, such wounds have prolonged healing, high susceptibility to infection and recurrence[3-6]. They cause severe pain, limb dysfunction and reduced quality of life, and impose heavy medical and economic burdens on families and society[7]. In clinical practice, local dressing therapy is core to diabetic ulcer management, aiming to create a favorable wound microenvironment to accelerate wound healing[8].
Hydrogel dressings have become a research hotspot in ulcer treatment due to their excellent biocompatibility[9]. However, functional hydrogel dressings currently in clinical use and development still face significant bottlenecks: Most target a single function such as antibacterial or moisturizing effects, failing to address the complex pathological microenvironment of wounds simultaneously[10]. To address these limitations, several multifunctional hydrogels have recently been developed[11]. For example, silver nanoparticle-loaded hydrogels and chitosan-based dressings have been widely explored for their potent broad-spectrum antibacterial activities[12]. Similarly, natural polyphenol-incorporated hydrogels (such as those using epigallocatechin gallate or curcumin) have shown promise in scavenging reactive oxygen species (ROS) at the wound site[13,14]. Nevertheless, these existing strategies often encounter practical hurdles: Silver-based materials can exert concentration-dependent cytotoxicity on healthy fibroblasts, and many natural antioxidants suffer from rapid degradation or poor stability within the wound microenvironment. In addition, local oxidative stress at the wound site exacerbates cell damage and inhibits repair processes, yet existing hydrogels lack sufficient or effective antioxidant components to alleviate oxidative stress injury, which severely limits improvement in their therapeutic efficacy[15]. Therefore, developing a novel hydrogel dressing with multi-target synergistic effects, high antioxidant capacity and superior biosafety holds important clinical value and scientific significance for eliminating bottlenecks in diabetic ulcer treatment.
Nicotinamide mononucleotide (NMN), a potent antioxidant, can effectively mitigate oxidative stress injury by participating in the synthesis of nicotinamide adenine dinucleotide (NAD+)[14,16]. Pluronic F127 is a classic thermosensitive material that remains liquid at low temperature and rapidly gelates upon contact with body temperature, facilitating wound application and tight adherence to the wound surface, thus serving as an ideal matrix for sustained drug release[17,18]. In our previous research, we loaded NMN into thermosensitive hydrogels, which effectively accelerated the healing of diabetic ulcers in mice. However, antibacterial activity was not prioritized in that study[19]. In the present study, we incorporated polyhexamethylene biguanide (PHMB) into the hydrogel system to address this limitation. As a highly effective broad-spectrum antibacterial agent with strong antimicrobial activity and low toxicity, PHMB efficiently inhibits the growth of common wound pathogenic bacteria and reduces infection risk[20].
This study incorporated NMN and PHMB as the core functional components and composited them with the Pluronic F127 thermosensitive matrix to construct a novel hydrogel dressing (PF/PHMB-NMN). The aim was to achieve the synergistic therapeutic effects of antibiosis-antioxidation-sustained drug release-repair promotion through the combined action of the three components. This study systematically characterized the biological functions of the composite hydrogel, verified its bacteriostatic activity, cytotoxicity and promoting effects on cell migration and angiogenesis via in vitro experiments, and evaluated its in vivo wound healing efficacy using diabetic mouse models, thus providing a novel strategy and candidate dressing for the clinical treatment of diabetic ulcers.
F127(Merck KGaA, Germany), NMN (TargetMol, CN) and PHMB (TargetMol, CN) were mixed at an appropriate ratio below 20 °C. The thermosensitive composite hydrogel (PF/PHMB-NMN) was prepared using the cold method, where Pluronic F127 was dissolved in double-distilled water at a final concentration of 20% (w/v) and stirred at 4 °C until a clear solution was formed. Subsequently, NMN and PHMB were incorporated into the F127 solution to achieve specific final concentrations of 5 mg/mL and 100 μg/mL, respectively, to ensure a synergistic therapeutic effect. The formulation ratios were optimized through a systematic screening process based on three primary criteria: (1) The concentration of F127 was selected to ensure the formulation remains liquid at room temperature (below 20 °C) while rapidly forming a stable gel upon contact with the wound surface at body temperature; (2) The PHMB concentration was screened to identify the minimum concentration required to maintain a bacteriostatic rate of approximately 100% against both Staphylococcus aureus (S. aureus) and Escherichia coli (E. coli); and (3) The final ratio was carefully balanced to ensure that the hydrogel extract maintained over 80% cell viability while preserving robust antimicrobial and antioxidant properties. This precise optimization addresses the potential cytotoxicity of PHMB while maximizing the metabolic regulation provided by NMN to facilitate effective wound healing.
Hydrogel extract preparation: The 1 mL hydrogel was solidified by incubation at 37 °C, 5 mL complete medium was added, static incubated at 37 °C for 24 hours, centrifuged at 800 g, and then the supernatant was collected and filtered through a 0.22 μm membrane for cell culture. HaCaT and EA.hy926 cells were prepared as single-cell suspensions with trypsin and seeded into 96-well plates at 5000 cells/well. After adherence, hydrogel extracts were added to each group. After 24 hours culture, CCK-8 working solution was added and incubated for another 2-3 hours, then absorbance was measured at 450 nm. Cell viability (%) = [(ODtest - ODblank)/(ODneg - ODblank)] × 100%.
Orbital venous blood was collected from Sprague-Dawley rats into heparinized centrifuge tubes, and red blood cells (RBCs) were isolated by centrifugation and diluted to a 10% RBC suspension with phosphate buffered saline (PBS) for use. A negative control (0.2 mL RBC suspension + 0.8 mL PBS, 0% hemolysis) and positive control (0.2 mL RBC suspension + 0.8 mL distilled water, 100% hemolysis) were included. For the test group, 0.2 mL RBC suspension was mixed with 0.8 mL extracts of different concentrations. All samples were incubated at 37 °C for 3 hours, then centrifuged at 4 °C and 3000 rpm for 10 minutes. Hemolysis was photographed, and the OD value of the supernatant was measured at 541 nm with a microplate reader. Hemolysis rate (%) = [(ODtest - ODneg)/(ODpos – Odneg)] × 100%.
The strains used in the experiment were E. coli and S. aureus. The activated strains were mixed with the original solution of the hydrogel extract at a volume ratio of 1:1. PBS buffer solution was used as the control group. The mixture was incubated at 37 °C for 1 hour. After incubation, the mixture was diluted 100 times and 100 μL of the diluted solution was spread on the no-antibiotic agar plate. The plate was inverted and cultured at 37 °C overnight. At the same time, groups with 5-fold and 10-fold dilutions of the hydrogel extract were set up. The incubation, dilution, spreading and cultivation were carried out according to the same steps as above. After the cultivation, the plates were photographed and recorded. Antibacterial rate (%) = [(colony number of control group - colony number of test group)/colony number of control group] × 100%.
Matrigel (Corning, United States) was mixed with pre-chilled serum-free medium at a 1:1 ratio, and100-150 μL was added to each well of a 48-well plate, then incubated at 37 °C for 30 minutes to form Matrigel-coated plates. After grouped treatment, cells were digested and adjusted to a density of 5 × 104 cells/200 μL, then seeded into the Matrigel-coated plates by group. The plates were cultured at 37 °C with 5% CO2 and saturated humidity for 2-6 hours to observe tube formation. After microscopic photography, Image J software was used to calculate the number of tubes and branches.
Cells were seeded in 6-well plates. Upon reaching 100% confluence, a 200 μL pipette tip was used to scratch a straight line vertically on the bottom plate with a ruler as reference. After aspirating to the medium, rinsing once with PBS and replacing it with fresh serum-free medium, the scratched area was marked and photographed under a microscope. Following 24 hours of further incubation, the same marked area was re-photographed to calculate the cell migration rate.
MaleBKS-db mice (purchased from Shanghai Model Organisms Center, China), aged 8-10 weeks, were housed in a SPF animal facility. All experiments were conducted following the Chinese Guidelines for Animal Research and were approved by the Ethics Review Committee of Fudan University. A diabetic mouse model was established via a high-fat diet combined with streptozotocin administration, with the mean blood glucose maintained at 22.71 ± 2.86 mmol/L. Under isoflurane anesthesia, the dorsal skin of mice was depilated and disinfected with ethanol, followed by the creation of a full-thickness wound with a diameter of approximately 1 cm. Mice were randomly divided into different groups for respective treatments, and wound images were captured at different time points during the treatment period. At the end of the experiment, mice were euthanized by CO2 inhalation, and the wound tissues were harvested for subsequent experiments.
Mouse skin tissues were paraffin-embedded and sectioned, followed by dewaxing in xylene and rehydration through graded ethanol. The sections were stained with hematoxylin for 5-10 minutes, rinsed with running water, differentiated in acid alcohol and blued with ddH2O. After staining with ponceau-acid fuchsin for 5-10 minutes and brief rinsing, they were differentiated with 1% phosphotungstic acid for 5-10 minutes, then stained with aniline blue for 5-10 minutes. Finally, the sections were dehydrated in graded ethanol, cleared in xylene, mounted with neutral balsam, air-dried and examined under a microscope.
A fluorescent multicolor staining kit (Servicebio, China) was adopted, and the procedure was briefly as follows: (1) Mouse skin paraffin sections were subjected to dewaxing; (2) Antigen retrieval and blocking; and (3) Followed by overnight incubation with primary antibodies. After washing with PBS, the sections were sequentially incubated with secondary antibody and the first fluorescent dye, and excessive fluorescent dye was removed by TBST washing. Antigen retrieval was performed again, and the subsequent steps were repeated until incubation with the second fluorescent dye. Then the cell nuclei were stained following incubation with API, washed with PBS, mounted with anti-fluorescence quenching mounting medium, and observed and photographed under a microscope after sealing. The primary antibodies CD31 (1:100) and Ki67 (1:200) used in this experiment were both purchased from Protein tech, China.
Tissue proteins were extracted using RIPA lysis buffer, quantified by BCA assay, and then subjected to high-temperature denaturation. Equal amounts of protein were loaded for SDS-PAGE electrophoresis, followed by transfer onto an activated PVDF membrane. Subsequently, the membrane was blocked with 5% non-fat milk, incubated with primary antibodies [vascular endothelial growth factor (VEGF) 1:1000, transforming growth factor-β1 (TGF-β1) 1:1000, and β-actin 1:20000, all purchased from Proteintech, China] at 4 °C overnight, washed with TBST, and then incubated with the corresponding secondary antibody at room temperature with shaking for 1 hour. After washing with TBST again, chemiluminescence detection was performed using an ECL kit, and images were captured.
Total RNA was extracted using Trizol reagent, and reverse transcription was performed with One-step RT-gDNA Digestion SuperMix (Yeasen, China) to obtain cDNA. For quantitative real-time-polymerase chain reaction, SYBR Master Mix (Yeasen, China) was used, and the relative expression levels were calculated using the 2-ΔΔCt method. The primers used are listed in Table 1.
GraphPad Prism software was used for statistical analysis and graph plotting in this study. All data are expressed as mean ± SD. The independent-samples t-test was adopted for comparisons between two groups, and one-way analysis of variance was used for comparisons among multiple groups. The above experiments were repeated at least three times (aP < 0.05, bP < 0.01, cP < 0.001).
The biocompatibility of the thermosensitive hydrogel was first evaluated. Given the certain cytotoxicity of PHMB, the stock hydrogel extract was appropriately diluted. As shown in Figure 1A, the 10-fold diluted extract of each hydrogel group exerted no significant adverse effects on the proliferation and viability of the two cell types. Hemolysis tests were then performed on the extracts of the four hydrogels, and the results (Figure 1B and C) demonstrated that the blank hydrogel and NMN-only hydrogel showed no hemolytic effect. The PHMB-containing hydrogels exhibited slight hemolytic activity at high concentration (approximately 9% at 2-fold dilution) but no hemolytic effect at low concentration (8-fold dilution), indicating excellent blood compatibility.In addition, the antibacterial capacity of the hydrogel was determined, and the results (Figure 1D and E) revealed that the PHMB-containing hydrogel extract, even at 10-fold dilution, could effectively inhibit bacterial growth, suggesting its potent antibacterial activity (100%). To further verify its broad-spectrum antibacterial activity, the inhibitory effect on E. coli was also evaluated. As shown in Figure 1F and G, the PF/PHMB-NMN hydrogel achieved a bacteriostatic rate of nearly 100% against E. coli, consistent with the findings for S. aureus. Collectively, these findings confirm that the thermosensitive hydrogel possesses favorable biosafety and antibacterial activity simultaneously.
Cell migration and angiogenesis play critical roles in skin wound healing. We evaluated the effects of hydrogel extracts from each group on the migration capacity of HaCaT cells and EA.hy926 cells via the scratch wound assay. For HaCaT cells, the cell migration rates of the PHMB group, NMN group, and PHMB + NMN group were all increased to varying degrees; whereas for EA.hy926 cells, only the NMN group and PHMB + NMN group exerted a promotive effect on cell migration (Figure 2A and B). In the vasculogenic tubule formation assay, the vascular structures formed by the hydrogels of the NMN group and PHMB + NMN group became more distinct and denser, with a significant increase in mesh number and branch number, indicating that the presence of NMN effectively promoted angiogenesis (Figure 2C and D). In summary, the PF/PHMB-NMN hydrogel can significantly enhance cell migration capacity and effectively promote angiogenesis, fully demonstrating that this hydrogel possesses the core potential to accelerate skin wound healing.
Subsequently, we evaluated the therapeutic efficacy of hydrogel in the mouse model. As shown in Figure 3, diabetic mice with skin injury received different treatments, and the wound healing status was observed at different time points. Compared with the other groups, the PF/PHMB-NMN hydrogel group exhibited a tendency toward wound area reduction as early as day 7. By day 21, the wounds in the PF/PHMB-NMN group were almost completely healed. These results demonstrated that the PF/PHMB-NMN hydrogel could significantly accelerate the skin wound healing process in diabetic mice, exhibiting excellent in vivo wound repair efficacy.
To further evaluate the hydrogel's effect on wound healing, the skin wounds underwent pathological examinations. As shown in the HE stains results of Figure 4A, the skin treated with PF/PHMB-NMN hydrogel exhibited more intact continuity, more newly formed granulation tissue, blood vessels and hair follicles, along with reduced inflammatory response compared with the other groups. Masson staining revealed that the blank group presented with less collagen synthesis, disordered arrangement and weak structure, reflecting impaired healing; in contrast, following treatment with PF/PHMB-NMN hydrogel, collagen deposition was increased and the arrangement regularity was restored to a certain extent (Figure 4B). In addition, tissue immunofluorescence assays also indicated that the mouse skin after PF/PHMB-NMN treatment contained more CD31+ blood vessels and Ki67+ cells, suggesting enhanced angiogenesis and cell proliferative activity (Figure 4C). These results demonstrate that the PF/PHMB-NMN hydrogel can effectively improve the quality of wound healing.
VEGF and TGF-β1 play pivotal roles in wound healing. VEGF can effectively promote the proliferation of vascular endothelial cells and the formation of new blood vessels, thereby providing sufficient blood supply for wound healing[21]. TGF-β1 can regulate the activation of fibroblasts as well as collagen synthesis and deposition, accelerating granulation tissue formation and wound remodeling[22-25]. Therefore, the expression levels of these two factors are key indicators for evaluating wound healing. The experimental results showed that the PF/PHMB-NMN hydrogel enhanced the transcriptional (Figure 5A and B) and protein (Figure 5C-E) expression levels of VEGF and TGF-β1 in wound tissues. These findings suggest that the PF/PHMB-NMN hydrogel may accelerate wound healing by upregulating the expression of VEGF and TGF-β1, thus improving angiogenesis, fibroblast function and extracellular matrix deposition.
The treatment of diabetic ulcers has long been a thorny clinical challenge due to their complex pathological microenvironment characterized by susceptibility to infection, oxidative damage and angiogenesis impairment, which often leads to prolonged non-healing of lesions[4]. As the core of diabetic ulcer management, local dressing therapy is crucial for optimizing the wound microenvironment and promoting healing. In this study, we prepared a thermosensitive PF/PHMB-NMN hydrogel with NMN, PHMB and Pluronic F127 for synergistic treatment of diabetic ulcers through multi-component synergy. In vitro experiments demonstrated that hydrogel possessed excellent biosafety (characterized by low cytotoxicity and no hemolysis), strong antibacterial activity, as well as the ability to promote cell migration and angiogenesis. It significantly accelerated wound healing and enhanced the expression of VEGF and TGF-β1 in skin tissues in the mouse model.
Infection has long been a major driver of impaired healing in diabetic ulcers. Impairment of the skin’s natural antibacterial barrier and immune dysfunction induced by hyperglycemia render infections prone to spread and are difficult to clear, and infection further exacerbates ulcer progression, thus forming a vicious cycle[26]. Traditional dressings tend to merely focus on exudate absorption and wound protection yet often lack antibacterial activity[9]. Therefore, antibacterial substances are frequently incorporated into the development of hydrogel dressings at this stage, such as silver ions, chitosan, or traditional Chinese medicine components (e.g., berberine)[11-13,27]. Benefiting from the drug sustained-release property conferred by the three-dimensional network structure of hydrogels, their antibacterial efficacy lasts longer[28]. Given the complex infection status of diabetic ulcers in clinical practice, which are often complicated by mixed infections with gram-positive bacteria, gram-negative bacteria and even fungi, there is an urgent need to select broad-spectrum antibacterial agents to achieve comprehensive bacteriostasis and prevent and control mixed infections[29]. Therefore, this study adopted PHMB, a clinically widely used broad-spectrum antibacterial agent, which exerts antibacterial effects while maintaining wound moistness, promoting epithelial repair, and causing minimal irritation to skin and mucous membranes[30,31]. Even when the extract of PHMB-containing hydrogel was diluted 10-fold in this study, it still maintained significant bacteriostatic activity against common pathogenic bacteria in wounds and exerted no significant inhibitory effect on the proliferation and survival of HaCaT and EA.hy926 cells. These results demonstrate that it retains excellent bactericidal activity within a non-toxic range, effectively balancing the antibacterial efficacy and biosafety of PHMB, and to a certain extent addressing the potential toxicity issues of PHMB in clinical application.
Cell migration and angiogenesis are two crucial processes in skin wound healing. Keratinocyte migration is essential for wound reepithelialization, while angiogenesis provides sufficient oxygen and nutrients for wound tissue repair[32]. In the in vitro experiments, we confirmed that the extract of PF/PHMB-NMN hydrogel significantly promoted the migration of HaCaT and EA.hy926 endothelial cells. In addition, the hydrogel groups containing NMN (the NMN group and PF/PHMB-NMN group) exhibited more distinct and dense vascular structures, and increased neovascularization was also observed in mouse models treated with PF/PHMB-NMN hydrogel. These effects are attributed to the biological functions of NMN, which have been proven to possess potent antioxidant and anti-aging properties[14,33]. Studies have shown that NMN can participate in the synthesis of NAD+, regulate cell metabolism and proliferation, thereby creating favorable conditions for endothelial cell migration and neovascularization[34,35]. Additionally, NMN can promote hair follicle neogenesis by inhibiting the nuclear factor-kappa B inflammatory signaling pathway in human dermal cells and upregulating the gene expression of VEGF and β-catenin[36]. Consistently, in this study, PF/PHMB-NMN hydrogel significantly upregulated the transcriptional and protein expression levels of VEGF and TGF-β1 in mouse wound tissues, and VEGF and TGF-β1 are recognized as key cytokines involved in wound healing. VEGF is a potent pro-angiogenic factor that effectively promotes the proliferation and migration of vascular endothelial cells and accelerates neovascularization[21]. TGF-β1 can regulate fibroblast activation, promote collagen synthesis and deposition, and accelerate granulation tissue formation and wound remodeling[22]. The upregulated expression of VEGF and TGF-β1 might potentially correlate with the activation of NAD-dependent protein deacetylase sirtuin-1 (SIRT1), and NAD+ is an important coenzyme of the SIRT1 pathway. Studies have demonstrated that SIRT1 can directly or indirectly upregulate the expression of VEGF and TGF-β1 by deacetylating and regulating transcription factors such as hypoxia-inducible factor-1 alpha[37,38]. However, this mechanism awaits further verification in subsequent experiments. Combined with the aforementioned results of enhanced cell migration and angiogenesis, it is hypothesized that the PF/PHMB-NMN hydrogel may be as follows: It inhibits bacterial proliferation in wounds and alleviates inflammatory responses via the sustained release of PHMB, and simultaneously releases NMN to mitigate oxidative stress damage, regulate cell metabolism, and upregulate the expression of VEGF and TGF-β1. Under the synergistic action of the two components, it promotes keratinocyte migration, endothelial cell angiogenesis, and fibroblast collagen synthesis, ultimately accelerating the healing of diabetic ulcer wounds.
Furthermore, it is essential to contextualize the role of multifunctional hydrogels within the broader integrated therapeutic strategy for diabetic foot ulcers. While our PF/PHMB-NMN hydrogel focuses on infection control and regenerative stimulation, clinical evidence underscores that successful diabetic foot ulcer healing fundamentally depends on the tissue perfusion status. As demonstrated in the clinical study by Cangiano et al[39], innovative revascularization techniques, such as IVUS-guided percutaneous deep foot vein arterialization, can significantly improve tissue oxygenation in diabetic patients with “no-option” critical limb ischemia. Their approach highlights that the restoration of adequate blood flow represents an essential prerequisite for effective biological repair processes. Consequently, advanced biomaterials like our PF/PHMB-NMN hydrogel should be viewed as synergistic components that act in concert with revascularization efforts. By providing an optimized microenvironment and promoting local angiogenesis, such hydrogels can maximize the therapeutic benefits of restored perfusion, ultimately facilitating wound closure in the complex clinical landscape of the diabetic foot.
Although this study achieved positive outcomes, it still has certain limitations. First, the in vivo experiments were only conducted on diabetic mouse models, whereas the pathological microenvironment of human diabetic ulcers is more complex (e.g., larger wound area, longer disease course, lack of chronic ischemia and polymicrobial infection, and more complications). Therefore, the therapeutic efficacy of this composite hydrogel for human diabetic ulcers needs to be further verified through subsequent large animal experiments and clinical trials. Second, this study only investigated the expression of VEGF and TGF-β1, and the specific molecular mechanisms underlying the regulation of wound healing by the composite hydrogel (e.g., involvement of other signaling pathways) remain to be further elucidated. In addition, it is necessary to evaluate the long-term safety under repeated administration conditions and expand the efficacy verification on wounds with mixed bacterial infections, which is more in line with the microbial ecological characteristics of clinical real-world wounds. Overall, the PF/PHMB-NMN hydrogel is by no means a simple passive wound covering material, but an active multifunctional dressing integrated as a functional system with antibacterial, anti-inflammatory and pro-regenerative signal regulatory properties, thus providing a novel strategy for the clinical treatment of diabetic ulcers.
In this study, by integrating NMN, PHMB, and F127, we developed a thermosensitive composite hydrogel dressing (PF/PHMB-NMN) with multi-target synergistic effects. In a preclinical setting, this hydrogel exhibited favorable biosafety and antibacterial activity. Furthermore, it demonstrated the potential to promote keratinocyte migration, angiogenesis, and collagen deposition – likely through the upregulation of VEGF and TGF-β expression – thereby contributing to the accelerated healing of diabetic ulcers in a mouse model. This study provides a promising candidate dressing for the management of diabetic ulcers and offers valuable insights into addressing the therapeutic challenges associated with chronic wound repair.
The authors would like to thank all colleagues and technical staff for their assistance and helpful discussions during the study. We are also grateful to the experimental center for providing the necessary facilities and support.
| 1. | Sun H, Saeedi P, Karuranga S, Pinkepank M, Ogurtsova K, Duncan BB, Stein C, Basit A, Chan JCN, Mbanya JC, Pavkov ME, Ramachandaran A, Wild SH, James S, Herman WH, Zhang P, Bommer C, Kuo S, Boyko EJ, Magliano DJ. IDF Diabetes Atlas: Global, regional and country-level diabetes prevalence estimates for 2021 and projections for 2045. Diabetes Res Clin Pract. 2022;183:109119. [RCA] [PubMed] [DOI] [Full Text] [Full Text (PDF)] [Cited by in Crossref: 8030] [Cited by in RCA: 6361] [Article Influence: 1590.3] [Reference Citation Analysis (15)] |
| 2. | Armstrong DG, Tan TW, Boulton AJM, Bus SA. Diabetic Foot Ulcers: A Review. JAMA. 2023;330:62-75. [RCA] [PubMed] [DOI] [Full Text] [Full Text (PDF)] [Cited by in Crossref: 1177] [Cited by in RCA: 1017] [Article Influence: 339.0] [Reference Citation Analysis (3)] |
| 3. | Mohsin F, Javaid S, Tariq M, Mustafa M. Molecular immunological mechanisms of impaired wound healing in diabetic foot ulcers (DFU), current therapeutic strategies and future directions. Int Immunopharmacol. 2024;139:112713. [RCA] [PubMed] [DOI] [Full Text] [Cited by in Crossref: 106] [Cited by in RCA: 70] [Article Influence: 35.0] [Reference Citation Analysis (0)] |
| 4. | Wang R, Gu S, Kim YH, Lee A, Lin H, Jiang D. Diabetic Wound Repair: From Mechanism to Therapeutic Opportunities. MedComm (2020). 2025;6:e70406. [RCA] [PubMed] [DOI] [Full Text] [Full Text (PDF)] [Cited by in Crossref: 1] [Cited by in RCA: 21] [Article Influence: 21.0] [Reference Citation Analysis (2)] |
| 5. | Pan Y, Chen L, Chen Y, Thomas ER, Zhou S, Yang Y, Liu K, Wu J, Li X. Mitochondrial dysfunction in diabetic ulcers: pathophysiological mechanisms and targeted therapeutic strategies. Front Cell Dev Biol. 2025;13:1625474. [RCA] [PubMed] [DOI] [Full Text] [Full Text (PDF)] [Cited by in Crossref: 11] [Cited by in RCA: 12] [Article Influence: 12.0] [Reference Citation Analysis (0)] |
| 6. | Xiong Y, Knoedler S, Alfertshofer M, Kim BS, Jiang D, Liu G, Rinkevich Y, Mi B. Mechanisms and therapeutic opportunities in metabolic aberrations of diabetic wounds: a narrative review. Cell Death Dis. 2025;16:341. [RCA] [PubMed] [DOI] [Full Text] [Full Text (PDF)] [Cited by in RCA: 64] [Reference Citation Analysis (0)] |
| 7. | Williams R, Karuranga S, Malanda B, Saeedi P, Basit A, Besançon S, Bommer C, Esteghamati A, Ogurtsova K, Zhang P, Colagiuri S. Global and regional estimates and projections of diabetes-related health expenditure: Results from the International Diabetes Federation Diabetes Atlas, 9th edition. Diabetes Res Clin Pract. 2020;162:108072. [RCA] [PubMed] [DOI] [Full Text] [Cited by in Crossref: 738] [Cited by in RCA: 570] [Article Influence: 95.0] [Reference Citation Analysis (4)] |
| 8. | Everett E, Mathioudakis N. Update on management of diabetic foot ulcers. Ann N Y Acad Sci. 2018;1411:153-165. [RCA] [PubMed] [DOI] [Full Text] [Full Text (PDF)] [Cited by in Crossref: 724] [Cited by in RCA: 587] [Article Influence: 73.4] [Reference Citation Analysis (1)] |
| 9. | Jiang P, Li Q, Luo Y, Luo F, Che Q, Lu Z, Yang S, Yang Y, Chen X, Cai Y. Current status and progress in research on dressing management for diabetic foot ulcer. Front Endocrinol (Lausanne). 2023;14:1221705. [RCA] [PubMed] [DOI] [Full Text] [Full Text (PDF)] [Cited by in Crossref: 118] [Cited by in RCA: 106] [Article Influence: 35.3] [Reference Citation Analysis (3)] |
| 10. | Wu H, Ni R, Shi Y, Hu Y, Shen Z, Pang Q, Zhu Y. The Promising Hydrogel Candidates for Preclinically Treating Diabetic Foot Ulcer: A Systematic Review and Meta-Analysis. Adv Wound Care (New Rochelle). 2023;12:28-37. [RCA] [PubMed] [DOI] [Full Text] [Cited by in Crossref: 29] [Cited by in RCA: 24] [Article Influence: 8.0] [Reference Citation Analysis (2)] |
| 11. | Wathoni N, Suhandi C, Ghassani Purnama MF, Mutmainnah A, Nurbaniyah NS, Syafra DW, Elamin KM. Alginate and Chitosan-Based Hydrogel Enhance Antibacterial Agent Activity on Topical Application. Infect Drug Resist. 2024;17:791-805. [RCA] [PubMed] [DOI] [Full Text] [Full Text (PDF)] [Cited by in RCA: 22] [Reference Citation Analysis (0)] |
| 12. | Li Z, Yang T, Li X, Yin P, Yang B, Li D, Wang Y, Teng W, Yu Q, Li W. A Bio-Responsive Hydrogel with Spatially Heterogeneous Structure for Treating Infectious Tissue Injuries. Adv Sci (Weinh). 2025;12:e2500088. [RCA] [PubMed] [DOI] [Full Text] [Full Text (PDF)] [Cited by in Crossref: 1] [Cited by in RCA: 9] [Article Influence: 9.0] [Reference Citation Analysis (0)] |
| 13. | Luan Q, Qiao R, Wu X, Shan J, Song C, Zhao X, Zhao Y. Plant-Derived Chinese Herbal Hydrogel Microneedle Patches for Wound Healing. Small. 2024;20:e2404850. [RCA] [PubMed] [DOI] [Full Text] [Cited by in Crossref: 11] [Cited by in RCA: 31] [Article Influence: 15.5] [Reference Citation Analysis (0)] |
| 14. | Yoshino J, Baur JA, Imai SI. NAD(+) Intermediates: The Biology and Therapeutic Potential of NMN and NR. Cell Metab. 2018;27:513-528. [RCA] [PubMed] [DOI] [Full Text] [Full Text (PDF)] [Cited by in Crossref: 920] [Cited by in RCA: 823] [Article Influence: 102.9] [Reference Citation Analysis (0)] |
| 15. | Ukaegbu K, Allen E, Svoboda KKH. Reactive Oxygen Species and Antioxidants in Wound Healing: Mechanisms and Therapeutic Potential. Int Wound J. 2025;22:e70330. [RCA] [PubMed] [DOI] [Full Text] [Full Text (PDF)] [Cited by in RCA: 77] [Reference Citation Analysis (0)] |
| 16. | Alegre GFS, Pastore GM. NAD+ Precursors Nicotinamide Mononucleotide (NMN) and Nicotinamide Riboside (NR): Potential Dietary Contribution to Health. Curr Nutr Rep. 2023;12:445-464. [RCA] [PubMed] [DOI] [Full Text] [Cited by in Crossref: 2] [Cited by in RCA: 58] [Article Influence: 19.3] [Reference Citation Analysis (0)] |
| 17. | Huang Y, Shi B, Liao Y, Zou G, Song K. Co-delivery of NGF and BMP-2 via thermosensitive pluronic F127 hydrogel enhances chondrogenesis and cartilage repair. Sci Rep. 2025;15:33354. [RCA] [PubMed] [DOI] [Full Text] [Cited by in RCA: 3] [Reference Citation Analysis (0)] |
| 18. | Dung TH, Huong LT, Yoo H. Morphological Feature of Pluronic F127 and Its Application in Burn Treatment. J Nanosci Nanotechnol. 2018;18:829-832. [RCA] [PubMed] [DOI] [Full Text] [Cited by in Crossref: 14] [Cited by in RCA: 21] [Article Influence: 2.6] [Reference Citation Analysis (0)] |
| 19. | Liang Y, Li M, Tang Y, Yang J, Wang J, Zhu Y, Liang H, Lin Q, Cheng Y, Yang X, Zhu H. Temperature-sensitive hydrogel dressing loaded with nicotinamide mononucleotide accelerating wound healing in diabetic mice. Biomed Pharmacother. 2023;167:115431. [RCA] [PubMed] [DOI] [Full Text] [Cited by in Crossref: 25] [Cited by in RCA: 25] [Article Influence: 8.3] [Reference Citation Analysis (0)] |
| 20. | Babalska ZŁ, Korbecka-Paczkowska M, Karpiński TM. Wound Antiseptics and European Guidelines for Antiseptic Application in Wound Treatment. Pharmaceuticals (Basel). 2021;14:1253. [RCA] [PubMed] [DOI] [Full Text] [Full Text (PDF)] [Cited by in Crossref: 59] [Cited by in RCA: 64] [Article Influence: 12.8] [Reference Citation Analysis (0)] |
| 21. | Liu J, Zhang Y, Liu C, Jiang Y, Wang Z, Guo Z, Li X. A single dose of VEGF-A circular RNA sustains in situ long-term expression of protein to accelerate diabetic wound healing. J Control Release. 2024;373:319-335. [RCA] [PubMed] [DOI] [Full Text] [Cited by in Crossref: 60] [Cited by in RCA: 50] [Article Influence: 25.0] [Reference Citation Analysis (0)] |
| 22. | Lichtman MK, Otero-Vinas M, Falanga V. Transforming growth factor beta (TGF-β) isoforms in wound healing and fibrosis. Wound Repair Regen. 2016;24:215-222. [RCA] [PubMed] [DOI] [Full Text] [Cited by in Crossref: 256] [Cited by in RCA: 478] [Article Influence: 47.8] [Reference Citation Analysis (0)] |
| 23. | Su J, Morgani SM, David CJ, Wang Q, Er EE, Huang YH, Basnet H, Zou Y, Shu W, Soni RK, Hendrickson RC, Hadjantonakis AK, Massagué J. TGF-β orchestrates fibrogenic and developmental EMTs via the RAS effector RREB1. Nature. 2020;577:566-571. [RCA] [PubMed] [DOI] [Full Text] [Cited by in Crossref: 140] [Cited by in RCA: 408] [Article Influence: 68.0] [Reference Citation Analysis (1)] |
| 24. | Trinh-Minh T, Chen CW, Tran Manh C, Li YN, Zhu H, Zhou X, Chakraborty D, Zhang Y, Rauber S, Dees C, Lin NY, Kah D, Gerum R, Bergmann C, Kreuter A, Reuter C, Groeber-Becker F, Eckes B, Distler O, Fabry B, Ramming A, Schambony A, Schett G, Distler JH. Noncanonical WNT5A controls the activation of latent TGF-β to drive fibroblast activation and tissue fibrosis. J Clin Invest. 2024;134:e159884. [RCA] [PubMed] [DOI] [Full Text] [Cited by in Crossref: 1] [Cited by in RCA: 45] [Article Influence: 22.5] [Reference Citation Analysis (0)] |
| 25. | Nigdelioglu R, Hamanaka RB, Meliton AY, O'Leary E, Witt LJ, Cho T, Sun K, Bonham C, Wu D, Woods PS, Husain AN, Wolfgeher D, Dulin NO, Chandel NS, Mutlu GM. Transforming Growth Factor (TGF)-β Promotes de Novo Serine Synthesis for Collagen Production. J Biol Chem. 2016;291:27239-27251. [RCA] [PubMed] [DOI] [Full Text] [Cited by in Crossref: 159] [Cited by in RCA: 145] [Article Influence: 14.5] [Reference Citation Analysis (0)] |
| 26. | Abad C, Safdar N. From ulcer to infection: an update on clinical practice and adjunctive treatments of diabetic foot ulcers. Curr Infect Dis Rep. 2012;14:540-550. [RCA] [PubMed] [DOI] [Full Text] [Cited by in Crossref: 3] [Cited by in RCA: 4] [Article Influence: 0.3] [Reference Citation Analysis (0)] |
| 27. | Yee MZL, Lim YW, Muthualagu Natarajan L, Czarny B, Ng KW. One-Step Tunable Human Hair Keratin Gradient Hydrogel with Antibacterial Activity for Tissue Engineering. Small. 2025;21:e09775. [RCA] [PubMed] [DOI] [Full Text] [Full Text (PDF)] [Cited by in RCA: 2] [Reference Citation Analysis (0)] |
| 28. | Ho TC, Chang CC, Chan HP, Chung TW, Shu CW, Chuang KP, Duh TH, Yang MH, Tyan YC. Hydrogels: Properties and Applications in Biomedicine. Molecules. 2022;27:2902. [RCA] [PubMed] [DOI] [Full Text] [Cited by in Crossref: 847] [Cited by in RCA: 532] [Article Influence: 133.0] [Reference Citation Analysis (0)] |
| 29. | Wu M, Guo F, He X, Zheng D, Ye W, Li S, Lin Z, Wang F. Analysis of Distribution and Drug Susceptibility Test Results of Pathogenic Bacteria in Diabetic Foot Ulcers. Diabetes Ther. 2024;15:1627-1637. [RCA] [PubMed] [DOI] [Full Text] [Cited by in RCA: 8] [Reference Citation Analysis (0)] |
| 30. | Ceviker K, Canikoglu M, Tatlıoglu S, Bagdatli Y. Reducing the pathogen burden and promoting healing with polyhexanide in non-healing wounds: a prospective study. J Wound Care. 2015;24:582-586. [RCA] [PubMed] [DOI] [Full Text] [Cited by in Crossref: 13] [Cited by in RCA: 11] [Article Influence: 1.0] [Reference Citation Analysis (0)] |
| 31. | Shi L, Stachon T, Seitz B, Wagenpfeil S, Langenbucher A, Szentmáry N. The Effect of Antiamoebic Agents on Viability, Proliferation and Migration of Human Epithelial Cells, Keratocytes and Endothelial Cells, In Vitro. Curr Eye Res. 2018;43:725-733. [RCA] [PubMed] [DOI] [Full Text] [Cited by in Crossref: 10] [Cited by in RCA: 15] [Article Influence: 1.9] [Reference Citation Analysis (0)] |
| 32. | Peña OA, Martin P. Cellular and molecular mechanisms of skin wound healing. Nat Rev Mol Cell Biol. 2024;25:599-616. [RCA] [PubMed] [DOI] [Full Text] [Cited by in Crossref: 1189] [Cited by in RCA: 886] [Article Influence: 443.0] [Reference Citation Analysis (1)] |
| 33. | Mills KF, Yoshida S, Stein LR, Grozio A, Kubota S, Sasaki Y, Redpath P, Migaud ME, Apte RS, Uchida K, Yoshino J, Imai SI. Long-Term Administration of Nicotinamide Mononucleotide Mitigates Age-Associated Physiological Decline in Mice. Cell Metab. 2016;24:795-806. [RCA] [PubMed] [DOI] [Full Text] [Cited by in Crossref: 432] [Cited by in RCA: 687] [Article Influence: 68.7] [Reference Citation Analysis (0)] |
| 34. | Das A, Huang GX, Bonkowski MS, Longchamp A, Li C, Schultz MB, Kim LJ, Osborne B, Joshi S, Lu Y, Treviño-Villarreal JH, Kang MJ, Hung TT, Lee B, Williams EO, Igarashi M, Mitchell JR, Wu LE, Turner N, Arany Z, Guarente L, Sinclair DA. Impairment of an Endothelial NAD(+)-H(2)S Signaling Network Is a Reversible Cause of Vascular Aging. Cell. 2018;173:74-89.e20. [RCA] [PubMed] [DOI] [Full Text] [Full Text (PDF)] [Cited by in Crossref: 429] [Cited by in RCA: 381] [Article Influence: 47.6] [Reference Citation Analysis (7)] |
| 35. | Kiesworo K, Agius T, Macarthur MR, Lambelet M, Lyon A, Zhang J, Turiel G, Fan Z, d'Almeida S, Uygun K, Yeh H, Déglise S, de Bock K, Mitchell SJ, Ocampo A, Allagnat F, Longchamp A. Nicotinamide mononucleotide restores impaired metabolism, endothelial cell proliferation and angiogenesis in old sedentary male mice. iScience. 2025;28:111656. [RCA] [PubMed] [DOI] [Full Text] [Cited by in RCA: 11] [Reference Citation Analysis (0)] |
| 36. | Xu C, Dai J, Ai H, Du W, Ji H. β-Nicotinamide Mononucleotide Promotes Cell Proliferation and Hair Growth by Reducing Oxidative Stress. Molecules. 2024;29:798. [RCA] [PubMed] [DOI] [Full Text] [Full Text (PDF)] [Cited by in RCA: 20] [Reference Citation Analysis (0)] |
| 37. | Liu X, Sui X, Zhang Y, Yue R, Yin S. Efficacy of puerarin in rats with focal cerebral ischemia through modulation of the SIRT1/HIF-1α/VEGF signaling pathway and its effect on synaptic plasticity. Heliyon. 2023;9:e15872. [RCA] [PubMed] [DOI] [Full Text] [Full Text (PDF)] [Cited by in RCA: 6] [Reference Citation Analysis (0)] |
| 38. | Zuo H, Liu X, Wang Y, Ding H, Wan W, Zheng S, Hou S, Hu K. SREBF1 facilitates pathological retinal neovascularization by reprogramming the fatty acid metabolism of endothelial cells. Exp Eye Res. 2025;252:110239. [RCA] [PubMed] [DOI] [Full Text] [Cited by in RCA: 5] [Reference Citation Analysis (0)] |
| 39. | Cangiano G, Corvino F, Giurazza F, De Feo EM, Fico F, Palumbo V, Amodio F, Silvestre M, Corvino A, Niola R. Percutaneous Deep Foot Vein Arterialization IVUS-Guided in No-Option Critical Limb Ischemia Diabetic Patients. Vasc Endovascular Surg. 2021;55:58-63. [RCA] [PubMed] [DOI] [Full Text] [Cited by in Crossref: 16] [Cited by in RCA: 19] [Article Influence: 3.8] [Reference Citation Analysis (0)] |