Ijn 18 1537

International Journal of Nanomedicine Dovepress
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REVIEW
Recent Advances in Nano-Drug Delivery

Systems for the Treatment of Diabetic Wound
Healing
Mengqian Liu , Xuerong Wei, Zijun Zheng, Yicheng Li, Mengyao Li , Jiabao Lin, Lei Yang
Department of Burns, Nanfang Hospital, Southern Medical University, Guangzhou, People’s Republic of China
Correspondence: Lei Yang, Department of Burns, Nanfang Hospital, Southern Medical University, Jingxi Street, Baiyun District, Guangzhou, 510515,
People’s Republic of China, Tel +86-20-6164-1841, Email [email protected]
Abstract: Diabetes mellitus (DM) induced wound healing impairment remains a serious health problem and burden on the clinical
obligation for high amputation rates. Based on the features of wound microenvironment, biomaterials loading specific drugs can
benefit diabetic wound treatment. Drug delivery systems (DDSs) can carry diverse functional substances to the wound site. Nano-drug
delivery systems (NDDSs), benefiting from their features related to nano size, overcome limitations of conventional DDSs application
and are considered as a developing process in the wound treatment field. Recently, a number of finely designed nanocarriers efficiently
loading various substances (bioactive and non-bioactive factors) have emerged to circumvent constraints faced by traditional DDSs.
This review describes various recent advances of nano-drug delivery systems involved in mitigating diabetes mellitus-based non-
healing wounds.
Keywords: drug delivery system, nanotechnology, diabetic wound healing, nanoparticles
Introduction
Diabetes mellitus (DM) is a complex chronic metabolic disease. Currently, over 300 million people suffer from DM, with
an increasingprevalence in the upcoming years.1,2 Diabetic patients in high glucose conditions always bear many
secondary complications, and diabetic foot ulceration (DFU) is a frequently recognized complication, which increases
amputation rates, and shortens lifespans.3,4 Many therapeutics have been applied in diabetic non-healing wounds, such as
hyperbaric oxygen therapy (HBO) and smart wound dressings.5 Diabetic wounds are heterogeneous, so the treatment and
outcome depend very much on precise strategies.6 Most of the current treatments are inadequate and incur a massive
financial burden to the patient. Therefore, the discovery of new therapeutic methods for diabetic wound healing is
urgently required.
A drug delivery system that delivers therapeutic molecules in a sustained release manner could be a promising
method of improving diabetic wound healing. These advanced systems can control drug release over a long time period,
maintain drug concentration and release drugs in a target site. Nevertheless, conventional drug delivery systems are not
always designed optimally for various drugs and inadequate to protect drugs from probable degradation, which causes the
waste of a large number of drugs.
Current developments of nanotechnology benefit the design and fabrication of drug delivery systems for diabetic
wound healing.7 With various nanostructures, such as liposomes, nanoparticles, nanofibers and nano hydrogels, these
nano-drug delivery systems are being studied to provide better drug performances and achieve maximum drug
encapsulation efficiency. Since NDDSs loading various carriers exhibit anti-inflammatory action, ROS scavenging,
reduction of local blood sugar levels and senescence cell clearance, their applications in diabetic wound treatment are
receiving increasing attention.8–10 A polycaprolactone (PCL)-based nanofiber has been fabricated to generate oxygen and
stimulate angiogenesis to improve diabetic wound healing.11 A Methacrylate Gelatin (GelMA) hydrogel based patch
International Journal of Nanomedicine 2023:18 1537–1560 1537

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carrying NO has been designed to accelerate diabetic wound healing.12 many other studies have also been reported to
explore the utilization of NDDSs in the field of diabetic wound healing.
In general, the reviews currently published on nano-drug delivery systems describe their unique properties and novel
fabrication technology. They give general insight into the application of nanomaterials in the wound healing field;
nevertheless, information about the application in specific wounds such as diabetic wounds is currently limited. In this
review, we cover all recent nano-scale drug delivery systems used for diabetic wound treatment. Additionally, it details
the major substances loaded in these nanocarriers and their function in accelerating diabetic wound healing, which would
help in selecting suitable drugs to meet the need of different diabetic wound conditions.
Wound Healing Pathophysiology

Normal Wound Healing
Wound healing is a complex and stepwise process and involves many different cell types releasing cytokines and growth
factors (GFs). The healing process is divided into the following overlapping stages: hemostasis, inflammation, prolifera
tion and remodeling (Figure 1).13–15
Fibrin plug formation can block bacteria and provide immediate coverage in the wound area.15 Platelets aggregate
and release proinflammatory mediators such as growth factor, cytokines and chemokines. These mediators can recruit
neutrophils and monocytes to the wound area, which support the armamentarium for the inflammatory period.16
The inflammation phase occurs immediately after injury and the focus of this phase is on destroying bacteria and
removing debris.17 This phase usually lasts four to six days, while in some pathological conditions (e.g., diabetic foot
ulcers), it can last for weeks or even months. Cell recruitment and chemotaxis (the movement of an organism in response
to a chemical stimulus) are key events in this phase. These cells have various functions. Increasing endothelial expression
of selectins slows down blood cells (e.g., leucocytes) and binding to integrins to help their adhesion. Neutrophils and
macrophages are involved in wound debridement, which also fuels the healing process by releasing cytokines, GFs and
other mediators.18 Circulating monocytes convert to tissue macrophages to aid wound contraction in the begin of
granulation tissue formation.19
The proliferation phase focuses on filling and covering the wound site, and it includes four distinct stages: re-
epithelialization, neovascularization, collagen synthesis and extracellular matrix (ECM) formations.20 This phase often
lasts for a few weeks. Granulation tissue formation is essential for wound contraction, and fibroblasts, endothelial cells
and keratinocytes are the most prominent cell types present and support the formation of granulation tissue, which is an
essential component of contraction.21 Physical contraction mediated by myofibroblasts also plays an important role in
achieving wound closure.22 Cross-talk between integrins, cells, cytokines and matrix metalloprotein (MMP) promotes
cell migration and ECM production.
Figure 1 The physiological process of normal wounds. (figure was created with BioRender.com).
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Figure 2 The pathophysiological processes of wound healing and diabetic wound healing. (figure was created with BioRender.com).
In the tissue remodeling phase, tissue slowly gains strength and flexibility. In this phase, many newly formed capillaries
subside, normalizing the vascular density of the wound site. To achieve proper tensile strength, ECM is reshaped to
a structure that approaches normal tissue.23 Gradually, the immature collagen (type lll) is converted into the more stable
collagen type l, and the ratio of type III and type I decreases. Collagen forms tight cross-links with collagen and other protein
molecules and deposits in a physiological alignment.24,25 This phase is relatively long, usually lasting 21 days to 1 year.
Diabetic Wound Healing

Under diabetic pathological conditions, the orderly and reliable healing process is disturbed and the wound becomes
a chronic wound.2,26 Some parts of the chronic condition may get stuck at different stages, losing the ideal synchrony of
healing progression that leads to rapid healing.27 There are intrinsic pathobiological abnormalities and extrinsic factors
that contribute to the occurrence of a diabetic wound (Figure 2).
Hypoxia is a major factor that causes a non-healing wound.28,29 In addition to inadequate oxygen supply, a prolonged
inflammation phase causes high oxygen consumption of wound cells.30 Diabetic neuropathy (DN) is the most common
complication of diabetes, and patients with an injured nerve system are more likely to develop diabetic foot ulcers. DN presents
a variety of manifestations, which include segmental demyelination, degradation of peripheral neuron axons, poor nerve
conduction and nutrient supply, culminating in dry skin and gangrene.31 Without pain perception, the patient is unable to feel
the injury site, consequently increasing the risk of infection and enlargement of the wound. Vasculopathy and endothelial cell
abnormalities, together with neuropathy, cause limited oxygen support to the wound area.32 Additional nerve damage, diminished
pain sensation and insufficient blood supply can amplify the disorder of the diabetic foot microenvironment. Wound healing
mediators can be influenced by high blood levels. The M2 type macrophage polarization is disturbed, the keratinocyte migration is
reduced, and the re-epithelialization stage is stagnant.33 Recent works revealed that a prolonged inflammatory phase is an iconic
feature of diabetic chronic wounds. With impaired phagocytic function, excess macrophages infiltrate the wound site and
influence MMPs regulation, which blocks deposition of intact, healthy collagen and formation of ECM.34
Current Diabetic Wound Treatment

Debridement
Debridement involves removing foreign debris, blood clots and the inactivated or infected tissue from a wound bed.35
The applied methods of debridement include surgery, wet-to-dry dressings, and enzymatic method.36 Sharp debridement
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has been well acknowledged as the gold standard for diabetic wounds, and it is reported that callus removal can rapidly
reduce pressure by 30%.37 Although debridement has been found to be efficacious in several clinical trials, its limitations
such as unacceptable pain and potential of second trauma are still a concern.38
Wound Dressings
Wound dressings are traditional elements of wound care, including natural, modified or synthetic materials and
therapeutic substances. Diabetic wounds are heterogenous, and there is no single dressing that has been reported to be
ideal for all wound types.39 An ideal wound dressing should provide a moist environment that promotes granulation,
revascularization, keratinocyte migration and tissue regeneration.40 It is a substantial challenge to develop an efficient
wound dressing, and many dressings has been created with novel bioengineering technology. However, current designed
dressings face various problems, such as cellular toxicity, allergic reactions, decreased angiogenesis and physiological
rejection.
Pressure Off-Loading
Pressure off-loading is a widely used treatment for patients with DFUs.41 The treatment can be distinguished in non-
removable, removable and surgical interventions.42 Several prospective controlled studies have shown that non-
removable, pressure off-loading casts are more effective, and a combination with surgical interventions (e.g., Achilles
tendon lengthening) can achieve more successful outcomes.43
Revascularization
Peripheral arterial disease (PAD) is the most common early-onset cardiovascular complication of diabetes. PAD is also
one of the strongest predictors of developing chronic wound and increasing risk of dying from cardiovascular disease. It
has been reported that PAD occurs in 40% of patients with DFUs.44 One of the most common treatments of PAD is
revascularization. Both pharmaceutical methods and surgical technologies (angioplasty, endarterectomy, grafting or
bypass) can be performed to achieve revascularization.
Treatment of Wound Infection

Infection is common in wound healing progress, especially in diabetic patients. Antimicrobial therapy is a common
method of wound infection, but it is not always necessary and does not apply in clinically uninfected wounds.45
Treatment of diabetic wound infection has been outlined by the IDSA, which recommends treatment of wounds with
two or more signs or symptoms of inflammation (erythema, fever, tenderness, pain and induration) or purulent
discharge.46 Due to antibacterial resistance and improper use of antibiotics, treatment of DFU infection can have adverse
outcomes. The strategy of applying narrow spectrum antibiotics within a short period can reduce healing time and
amputation rate. Besides oral or intravenous administration of antibiotics, nanomaterial-based systems have emerged as
a promising method for antibiotic delivery, which improve therapeutic index and avoid antibacterial resistance.47
General Measures
In addition to medication and surgical treatment, good glycemic control is a very important general therapeutic method
for DFU. Patients should also pay attention to normalization of blood indicators, the management of blood fat, drinking
and smoking cessation and diet control.48 Since hyperglycemia plays the most important role in DM pathology, good
blood sugar control can not only have a positive effect on DFU outcomes but also delay the onset of other complications
of diabetes.49 Also, several observational studies have found that there is a linear correlation between appropriate
nutrition supplement and DFU prognosis.50
Substances
The pathological process of diabetic wound healing includes complex changes and some key factors associated with
successful healing are in disorder. Thus, various substances should be applied to support this progress. Substances loaded

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in NDDSs for diabetic wound healing can be classified into two categories: bioactive molecules and non-bioactive
substances.
Bioactive Molecules
Growth Factors
Growth factors are multi-functional polypeptides, which bind to specific, high-affinity cell membrane receptors to
mediate, coordinate and control cellular interactions.51 Growth factors can stimulate cell proliferation and differentiation
to benefit overlapping phases of wound healing and accelerate this process.52 The transforming growth factor (TGF-β)
superfamily has mainly three isoforms, TGF-β1, β2 and β3, and TGF-β1 has been recognized as a key modulator of
cutaneous wound healing. Preclinical studies showed that low expressions of TGF-β1 and TGF-β2 reduced scar
formation and improved dermal architecture.53 The vascular endothelial growth factor (VEGF) acts as a signaling
mediator in neovascularization.54 By interacting with VEGF receptors (VEGFR) to stimulate downstream signaling
cascades, VEGF controls fibroblasts and endothelial cells function and promotes their proliferation.55 The platelet-
derived growth factor (PDGF), mainly secreted from platelets, mediates wound healing throughout all phases. PDGF
targets dermal fibroblasts and many other cells to promote collagen synthesis and dermal regeneration. The epidermal
growth factor (EGF) activates downstream signaling pathways and induces cell migration and proliferation. EGF
interacts with keratinocytes to promote their migration, which is crucial for the re-epithelialization process.56 The
fibroblast growth factor (FGF) can promote endothelial cell migration and smooth muscle cell proliferation. Among
the subfamilies of FGF, FGF2 has been applied for scarless wound healing.57
An impaired balance of many growth factors and disturbance of various cellular responses mediated by GFs have
been reported in chronic non-healing wounds.58 Therefore, locally applying exogenous growth factors can achieve
positive outcomes of wound injury treatment.59 There are medications containing recombinant human EGF (rhEGF) that
are commercially available and have been used in clinical treatment, such as Heberprot-P®,60 Regen-D™ 150, and
Easyef®.61 Many studies have suggested that the function of GFs is spatially related,62 however conventional
systems lack the ability to control the release of GFs spatially and temporally. Currently, various sophisticated delivery
systems for delivery growth factors have been reported for diabetic wounds (Table 1).63–70
Table 1 Delivery of Growth Factors with Nanocarriers

GFs Carriers Function Merits Refs.
EGF PHBV-GelMA hybrid Promote the migration and proliferation of multiple types of Good biostability [64]
patch cells (keratinocytes, fibroblasts and endothelial cells) and
enhance angiogenesis.
EGF Chitosan nanoparticles Induce thorough re-epithelialization, sufficient collagen Good biocompatibility [63]
deposition, and accelerated collagen maturation.
bFGF Decellular dermal matrix Enhance granulation tissue formatting, angiogenesis and Good endothelial [65]
collagen deposition. inducibility
rhEGF Nanofiber scaffolds Induce faster wound healing activity in dorsal wounds. Electrospinning fibers; [66]
prolonged the release of
GFs
EGF Chitosan/PVA hetero- Reduce inflammatory response, faster collagen deposition, and Release EGF and PHMB in [67]
composite hydrogel advanced collagen maturation. ion-rich environment
PDGF-BB Nanohydrogel Destruct biofilm. Destruct the biofilm; keep [70]

stable structure at room
temperature
rhEGF Sodium carboxymethyi Exhibit more stability against proteolysis and preserve Increasing GFs proteolytic [69]
chitosan nanoparticles biological activity. resistance

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EGF has an excellent mitogenic effects on epithelial, fibroblastoid and endothelial cells.68 It is interesting to note that
the complex microenvironment of DFU is hostile for the production and secretion of EGF and exhibits downregulation of
EGF and its receptor.71 Current challenges facing the additional EGF treatment is short half-life and repeated
administration.72 A hybrid biomaterial patch is a promising approach for loading the GFs.73 Auguastine et al64
encapsulated EGF in porous nanofiber membranes and hybrid with GelMA hydrogel to form a biodegradable polymeric
patch for diabetic wound healing.
Genes/Proteins/Peptides
A gene therapy involves transfection of specific genes to correct genetic disorders. Diabetic wound environments have
a complicated genetic disorder, and manipulating gene levels can be promising for the non-healing wound. Several
studies have showed microRNAs (miRNAs) regulate post transcriptional gene expression and can be a promising nucleic
acid drug for diabetic wound.74 Recently, miR-129 and −335 have been identified as a negative regulator of MMP-9
expression by targeting specific protein-1 (Sp1).74 Gene therapy faces many challenges, transfection via virus has
carcinogenic potential.75 Rapid degradation and repeated administration of gene therapy agents (e.g., nucleic acids,
proteins, peptides) can amplify the adverse effect. NDDSs can provide a system for better circulating concentration and
precise modulation at the target site. Yan et al76 reported milk-derived exosomes to deliver miRNA, which are fabricated
through electroporation and achieved higher cell uptake and were able to resist degradation.76 In vivo results showed this
novel system promoted angiogenesis and enhanced diabetic wound healing.76 Small interfering RNA (siRNA) mainly
involves the RNA interference (RNAi) phenomenon and induces gene silencing post-transcriptionally.77 Shaabani et al78
formulated siRNA into a layer-by-layer platform with a tunable outer surface to increase angiogenesis factors in diabetic
wound area. They focused on the stabilization of HIF-1α, which is crucial for activating angiogenesis factors. Layer-by-
layer self-assembled siRNA-loaded nanocarriers can delivery siRNA downregulating PHD-2 to stabilize HIF-1α and then
increase pro-angiogenic factors level. The report also found these layer-by-layer nanoparticles can prevent endosomal
escape and improve transfection efficiency. Currently, various nanocarriers loaded gene therapy agents have been
reported. See Table 278–96 for other systems.
Table 2 Delivery of Genes/Proteins/Peptides with Nanocarriers for Diabetic Wound Healing

Cargos Carriers Functions Refs.
Keap1 siRNA Lipoproteoplex (LPP) nanoparticle Restore Nrf2 antioxidant function; accelerate [79]
diabetic tissue regeneration, and augment
reduction-oxidation homeostasis in the wound
environment.
MMP-9 siRNA (siMMP-9) Hyperbranched cationic polysaccharide Reduce MMP-9 expression, and improve diabetic [80,81,196]
derivatives (HCP); hydrogel based on Pluronic wound closure.
F-127 (PF) and methylcellulose (MC); chitosan
nanoparticles
siRNA-29a gene HA-PEI nanoparticles Accelerate the diabetic wound healing, [82]
angiogenesis factors (α-SMA and CD31)
production; inhibit pro-inflammatory factors (IL-6
and TNF-α).
siRNA (downregulation of Gold nanoparticles (AuNPs) Improve the endosomal escape of siRNA; induce [78]
PHD-2) PHD-2 silencing in fibroblasts; allow upregulation
of pro-angiogenic pathways.
Dicer substrate small Gold nanoparticles (AuNPs) Enhance PGE2 production and vascularization; [83,84]
interfering RNA improve vascularization by inhibiting PGT gene
(DsiRNA) expression.
(Continued)

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Table 2 (Continued).
Cargos Carriers Functions Refs.
MicroRNA (miRNA) Milk-derived exosomes Promote the proliferation, migration, and [76]
miR-31-5p angiogenesis of endothelial cell.
miR146a Cerium oxide nanoparticles (CNP) Scavenge free radical, inhibit NFκB pathway, anti- [93]
inflammation performance.
LncRNA-H19 High-yield extracellular vesicle-mimetic Neutralize the regeneration-inhibiting effect of [85]

nanovesicles (EMNVs) hyperglycemia.
Antimicrobial peptide Ultra-small gold nanoparticles Enhance cellular and nucleus entry to achieve high [86]
(LL37) gene delivery efficiency.
Bioactive peptides Chitosan NPs Shorten the inflammatory stage and promote [87]
neovascularization.
P311 peptides Micelles Ros-trigged P311 release to reduce oxidative [94]

stress and inflammation.
CCN1 Nanoformulation Increase CCN1 intracellular expression, decreses [95]

inflammation.
PDGF-BB proteins Fibrin-based hydrogel Induce angiogenesis and arteriogenesis. [88]
L-Glutamic acid Chitosan (CS) hydrogels Accelerate vascularization and macrophage [89]
recruitment.
Neurotensin (NT) Polylactide-polyglycolide (PLGA) and cellulose Induced more rapid healing; decreased the [90]
nanocrystals (CNCs) (PLGA/CNC) nanofiber expressions of the inflammatory cytokines IL-1β
membranes and IL-6.
Recombinant human PDA@Ag NPs Promote the proliferation and migration of [91]
collagen type III mouse fibroblasts and endothelial cells; promote
(rhCol III) the expression levels of basic fibroblast growth
factor (bFGF) and vascular endothelial growth
factor (VEGF).
Recombinant human Nanostructured lipid carrier (NLC) Improve wound healing and cell migration. [92]
thrombomodulin (rhTM)
VEGF-A mRNA Ionizable lipid-mediated nanoparticles (LNP) Upregulate VEGF-A expression, expedite healing [96]
progress.
Stem Cells/Exosomes
Stem cells (SCs) are a class of cells with multiple differentiation potential and self-renewal ability, and their main
features are pluripotency, indefinite division and the ability to promote cytokines secretion.97 Due to their immunomo
dulatory properties and easily controlled dosage, stem cells therapy has flourished in the field of regenerative medicine
and wound healing.98 The mesenchymal stem cells (MSCs) can be derived from various sites, and their ability of
multilineage differentiation makes them good candidates for wound healing. Their immune response properties should be
considered, and studies have showed that the immune modulation can enhance wound healing.99 Most of the MSCs are
derived from bone marrow, compared with MSCs, the adipose-derived stem cells (ADSCs) are less invasive and have no
ethical limitations. ADSCs can differentiate to endothelial cells and secrete VEGF to promote wound healing.100
Although many studies have showed that stem cell therapy can improve skin regeneration, their poor survival rate and
proliferation capacity shrink their application efficiency. Thus, the mixture of SCs or stem cells exosomes (SCs-exos)
with finely-designed NDDSs could be an ideal strategy. Xu et al101 developed an injectable hydrogel with hyperbranched

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PEG macromer for stable delivery of ADSCs that promote tissue regeneration. Moreover, hypoxia-induced conductive
hydrogel incorporating ADSCs can promote the reconstruction of blood vessels, hair follicles and dermal collagen
matrix.102 However, stem cells face some limitations such as issues of storage and transportation and risks of tumor
formation.103 Exosomes are 40–100 nm sized extracellular vesicles, derived from paracrine secretion of most cell
types.104 With stable and easily stored characteristics, they can overcome limitations of stem cells therapy.105 See
Table 38,106–113 for more information.
Yang et al111 reported Pluronic F127 hydrogel loaded with human umbilical cord-derived mesenchymal stem cell-
derived exosomes (hUCMSC-exos). This delivery system efficiently delivered hUCMSC-exos and promoted diabetic
wound healing. It can also increase expression of proliferating cells related signals, enhance granulation tissue formation
and upregulate growth factor expression.
Thus, biomaterial-based exosomes therapy holds great promise in cutaneous wound treatment and regenerative
medicine.114
Table 3 Stem Cell/Exosomes Loading Nanomaterial for Diabetic Wounds

Stem Cells/ Delivery Systems Functions Models Refs.
Exosomes
BMSCs Nanofiber scaffolds; human Promote granulation tissue formation, Cutaneous wounds of [8,106,107]
epidermal growth factor-curcumin angiogenesis, and collagen deposition, streptozotocin-induced
bandage bioconjugate (EGF-Cur and switch the immune responses to diabetic mice
B); N-chitosan/HA-ALD hydrogel the pro-regenerative direction;
stimulate secretion of growth factors
from bone marrow mesenchymal stem
cells (BM-MSCs) and regulate the
inflammatory environment by inhibiting
the expression of M1 macrophages and
promoting the expression of M2
macrophages
ADSCs Injectable hydrogels Promise regenerative capabilities; STZ-induced mice [101,102]

promote the reconstruction of blood
vessels, hair follicles, and dermal
collagen matrix.
Gingival mesenchymal Chitosan/Silk hydrogel sponge Promote the re-epithelialization, STZ-induced mice [108]
stem cells (GMSCs) deposition and remodeling of collagen
by enhancing angiogenesis and
neuronal ingrowth.
hFDSPC HA Improve re-epithelialization, STZ-induced mice [110]

angiogenesis, anti-inflammation,
collagen regeneration, and maturation.
Mesenchymal stem ADM-RGO composite scaffolds Support robust vascularization and STZ-induced rats [109]
cells (MSCs) collagen deposition as well as rapid re-
epithelialization during diabetic wound
healing.
hUCMSC-exos Pluronic F-127 (PF-127) hydrogel Efficient delivery of hUCMSC-exos; STZ-induced rats [111]
accelerate wound closure rate.
Platelet-rich plasma Chitosan/Silk hydrogel sponge Accelerate vascularization and collagen STZ-induced rats [112]
exos deposition.
MSC s PLGA NPs Induce capillary construction and STZ-induced mice [113]
collagen deposition.

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Drugs
A wide range of drugs have been proved to exhibit significant efficacy for wound healing. The nanoscale local drug
delivery system, as an ideal carrier, has been fabricated to overcome the limitations (such as low physico-chemical
stability, low bioactive absorption, poor pharmacokinetics etc.) of these drugs (Table 4).10,111,115–131
Curcumin is a natural polyphenol obtained from turmeric.132 This natural bio-substance is often used as an
antioxidant and anti-inflammatory agent, and can aid various stages of the wound healing process.133 However, just
like other small hydrophobic molecules, curcumin shows low stability in wound healing treatment, especially for topical
Table 4 Delivery of Drugs for Efficient Diabetic Wound Healing

Drugs Carriers Functions Merits Refs.
Curcumin 1. Injectable hydrogel; Increase angiogenesis and collagen deposition; alleviate Good swelling properties; [111,120,125,126,185]
2. hyaluronic acid (HA) and inflammation and oxidative stress. a controlled release profile
chitosan-based hydrogel
(OHA-CMC);
3. Gelatin microspheres
(GMs); Curcumin-micelles;
4. Polycaprolactone-/polyvinyl
alcohol-silk fibroin based
electrospun nanofibrous mat
Insulin pH and glucose dual- Promote neovascularization and collagen deposition and pH and glucose dual- [115,187]
responsive injectable enhance the wound-healing process. responsive; core-shell
hydrogels; PLGA nanofibrous structure
scaffolds
Quercetin (QCN) Topical hydrogel system Improved scratch-wound recovery of keratinocytes and Highly skin-permeable; [116]
fibroblasts. topical delivery of QCN and
oxygen
Huangbai liniment Silk fibroin (SF) /poly- Increase the expression of the TGF-β signaling pathway and Increased drug [117]
(Compound (L-lactide-co-caprolactone) collagen during wound healing, inhibits the expression of pro- concentration; inhibitory
Phellodendron Liquid, (PLCL) (SP) nanofiber inflammatory factors. effects for S. aureus and
CPL) membrane E. coli.
Dimethyloxalylglycine Porous electrospun fibrous Improve neo-vascularization, re-epithelialization and collagen Aligned porous; controllable [118]
(DMOG) membrane formation. released DMOG drugs from
the membranes
Hyaluronan pH-responsive calcium Promote angiogenesis; enhance expression of vascular Multifuctional [119]
oligosaccharide alginate hydrogel endothelial growth factor.
Antidiabetic agents Nanofibrous scaffolds Lower proinflammatory cytokine levels; improve neutrophil Stimuli-responsive [10,122]
(metformin, infiltration, edema, and inflammation and increased metformin release;
pioglitazone, epidermal regeneration and fibroblast proliferation. multifunctional
glibenclamide)
Antibiotic agents Fibrous mats; nanocomposites Efficient bacterial clearance; induce faster chronic wound Provide strong bacteria [121,124,137]
(cephradine, healing. adhesion; destroy biofilm
ciprofloxacin,
gentamicin)
Gallic acid Microneedle patch Scavenge reactive oxygen species, promotes antioxidation. Transdermal delivery and [123]
combination therapy
Clindamycin Ceria nanoparticles (CNP) Antibacterial effect, scavenge ROS. ROS responsive; apply drugs [127]
conjugated CNP to treat
DFU
Gentiopicroside m-PEG/PVP nanofibers Antibacterial effect, achieve better skin architecture. Could be fabricated via [128]
(GPS) and electrospinning method
Thymoquinone (TQ)
Berberine Polyvinyl alcohol (PVA), Promote wound healing, inhibit NF-κB, TNF-a Intracellular mechanism has [129]
sodium alginate (Alg) based been demonstrated:
nano-colloids hydrogel activating Sirt 1/NF-κB
pathway
Resveratrol Resveratrol-laden Antioxidant effect, reduce macrophage iNOS level. Two drugs synergetic effects, [130]
nanoparticles sustained drug release
Asiaticoside Polymeric nanoparticles Increase collagen biosynthesis, enhance COL-1 protein level. Obtain ideal drug release [131]
kinetics, improve
intra-cellular uptake

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application.134 Liu et al125 enclosed self-carried Cur nanoparticles (CNPs) in gelatin microspheres (GMs), which can
respond to the overexpression of MMP-9 in the wound environment, and the CNPs@GMs have been loaded into
a thermo-sensitive hydrogel to facilitate the healing process. Recently Hu et al120 reported a hyaluronic acid (HA) and
chitosan-based hydrogel (OHA-CMC) for loading and delivering CNPs. Benefiting from the encapsulated CNPs, this
formulation exhibited excellent antioxidant and anti-inflammatory ability and presented on-demand drug release.
Antidiabetic agents such as metformin (MET), pioglitazone (PHR) and glibenclamide (GB) have been confirmed to
exhibit strong anti-inflammatory effects, which can be applied in the research of accelerating diabetic wound healing.
Cam et al10 loaded three types of oral antidiabetic agents into nanofibrous scaffolds based on two different polymer
composites mixtures (CS/GEL/PCL and PVP/PVL), to improve type I diabetic wound healing. In a previous study, Cam
et al122 have confirmed PHR loaded fibrous mats have high potential for targeting inflammatory and proliferation phases
of DFU; in follow-up studies, they further demonstrated that PHR&MET and PHR&GB exhibited better healing rate then
single usage of PHR.
Non-Bioactive Substances
Metal Ion
Metal ion nanoparticles have attracted extensive attention as an appreciable option to antibiotics.135 Among various
metallic elements, silver (Ag) is the most studied for its strong and long-lasting antibacterial properties against various
pathogens and microorganisms.136 Though the inherent mechanisms of AgNPs antibiotic ability are still unclear, it
is recognized that AgNPs can destroy the cell wall or cell membrane. Wang et al137 showed that Ag nanocubes with
a virus-like mesoporous silica coating improved cell wall adhesion and completely eradicated pathogenic bacteria in the
wound site. Gold (Au) nanoparticles are also reported as an anti-infection agent. Their inert and nontoxic nature makes
them an ideal material as the core of NPs. Researchers have demonstrated AuNPs can strongly resist both Gram-negative
and Gram-positive pathogens and do not develop drug resistance.138 Currently, copper NPs (CuNPs) are drawing
considerable attention as antibiotic agents for wound healing. Their high redox potential makes them effective against
a broad-range spectrum of bacterial species, and they have relatively low cost compared with Ag and Au.139 Our review
gives more information of metal ion nanoparticles in the drug delivery system section.
Oxygen
With more in-depth understanding of the mechanism of chronic wound healing progress, a prolonged hypoxic environ
ment has been confirmed as one of the causes of healing impediment.140
Several advanced treatments for proper oxygen supply are currently available on the market, such as hydrofiber®
dressings.141,142 Nanomedicine have been introduced to fabricate oxygen-releasing systems, and scientific studies have
emerged to design and fabricate tunable platforms in terms of controlling oxygen supplementation.29 Currently, various
oxygen-containing nanocarriers have been shown to reverse the hypoxic environment of diabetic wounds
(Table 5).9,11,12,67,143–154
Table 5 Delivering Oxygen/NO for Diabetic Wound Treatment

Materials Carriers Functions Refs.
Oxygen Microspheres Augment the survival and migration of [144]

keratinocytes and dermal fibroblasts; promote
angiogenic growth factor expression and
angiogenesis.
Calcium peroxide OxOBand Facilitate faster wound closure, enhance [145]

collagen deposition, faster re-epithelialization,
increased neo-vascularization, and decreased
oxidative stress.
(Continued)

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Table 5 (Continued).
Materials Carriers Functions Refs.
Sodium per carbonate (SPC) Plycaprolactone (PCL)-based nanofibers Pronounce expression of HIF-1α; improve [11]
angiogenesis.
QCN oxygen Nanoemulsion (NE) Accelerate wound-healing. [116]
Perfluorocarbon emulsions Chitosan nanoparticles Alleviate hypoxia conditions on diabetic [67]

wounds.
MnO2 Dex-SA-AEMA (DSA) hydrogel; Convert the endogenous hydrogen peroxide [9,146]
crosslinking hydrophilic poly(PEGMA-co-GMA- (H2O2) into oxygen (O2).
co-AAm) (PPGA) polymers with Reduce oxidative stress, decrease ROS level,
hyperbranched poly-L-lysine (HBPL)-modified shorten inflammatory phase.
nanosheets
Oxyhemoglobin/hydrogen MXene nanosheets Keep the intracellular redox homeostasis and [147]
(HbO2/H2O2) alleviate oxidative stress.
S-Nitroso- Hitosan/polyvinyl-alcohol hydroge; GelMA Continuous cell-proliferating activity; speed up [148,149]

N-acetylpenicillamine (SNAP) hydrogel the healing process; upregulate of VEGF and
SDF-1α biomarkers.
Nitric oxide (NO) Copper-benzene-1,3,5-tricarboxylate HKUST- Promote a more accurate and deeper delivery [12,150,151]
1;dinitrosyl iron complexes (DNICs) of NO molecules into the wound site.
Glucose oxidase (GOx) Ceria nanozymes; Zn-MOF nanoparticle Reduce hydrogen peroxide level, regulate the [152,153]
oxygen balance.
ZnO Nanofibers Sustained release two bioactive agents. [154]
Sodium percarbonate (SPC), as a strong oxidant, has been found to be a potential oxygen-generating agent to
accelerate healing in a chronic non-healing wound. Oxygen generation of SPC is peroxide-based, releasing hydrogen
peroxide in water solution and ultimately oxygen on decomposition.143 Zehra et al11 reported a PCL polymer-based
dressing, which encapsulated oxygen generator SPC to improve the hypoxia in wound site. Their results showed that the
novel dressing could release sufficient oxygen at the wound site for a long period and significantly improve angiogenesis.
However, reactive oxygen species (ROS) is another existing form of oxygen element in the wound microenvironment,
and abnormally high levels of ROS can inhibit wound healing processes and cause a non-healing wound. Recently, nitric
oxide (NO), as an important ROS scavenger, is considered to play a pivotal role in healing process pathology of diabetic
wounds. Hyperglycemic conditions in the diabetic wound environment can inhibit the synthesis of endogenous NO.
Topical NO delivery have received more and more attention, and there are several donors that have been investigated for
NO delivery such as organic nitrates and nitrites, metal-NO, diazeniumdiolates (NONOates) and S-nitrosothiols
(RSNOs).155 Zhang et al12 recently developed HKUST-1, a novel MOF system with unsaturated Cu metal site, to deliver
NO. With highly designable structure, the nanomaterial scaffold released NO with an ideal concentration and
promoted angiogenesis and collagen deposition.
Nano-Drug Delivery System

NDDSs refer to drug delivery systems with particle diameter within the nanoscale, which have the feature of improving
drug stability, sustained release and controlled release of drugs, and they can be fabricated with a variety of
biomaterials.156 An unprecedented number of NDDSs loading therapeutic agents have emerged and these are being
used in diabetic wound treatment. NDDSs can be classified into liposomes, polymeric nanoparticles, inorganic nano
particles, lipid nanoparticles, nanofibrous structures and nanohydrogel (Figure 3).

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Figure 3 Schematic representation of nano-drug delivery system used for diabetic wound healing: Liposomes, Polymeric nanoparticles, inorganic nanoparticles, lipid
nanoparticles, nanofibers, nano-hydrogels. (figure was created with BioRender.com).
Liposomes
Liposomes are artificial membranes mainly composed of amphiphilic molecules, which form a bilayer structure similar to
the structure of skin cell membranes. With drugs encapsulated in the hollow part of the lipid-like bilayer, liposomes are
advanced nano-carriers for drug delivery.157
With their intrinsic merits such as biodegradability, lower systemic toxicity and targeted delivery, liposomes have
been universally applied in drug delivery and made their way to the market.158 A total of 14 liposome products have been
approved for marketing.159 These liposomal products are primarily focused on oncology treatment. Currently, increasing
novel liposomes with modified surfaces are springing up to cover the shortage of conventional vesicles in the field of
chronic wounds.160
Chhibber et al161 prepared a novel liposome which efficiently entrapped bacteriophages. The vehicles remarkably
improved phage persistence in situ. The results showed that liposomal entrapment of phage cocktail significantly
reduces wound bioburden, accelerates wound contraction and speeds tissue healing. It was fully confirmed that the
liposome entrapped with phage cocktail overcomes the major drawback of phage therapy and addresses a Staphylococcus
aureus-induced chronic wound infection.
Rabbani et al79 reported a lipoproteoplex (LPP) siRNA delivery vehicle, targeting the Keap1/Nrf2 pathway associated
with impaired diabetic wound pathology, thereby promoting wound healing. A stable LPP nanoparticle is produced of
a cationic lipid nanoparticle (CLN) as a primarily lipid-based vehicle, and a cationic engineered supercharged coiled-coil
protein (CSP) has been engineered to enhance transfection efficacy. The novel system overcomes traditional challenges

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facing RNAi therapy, which uses lipid or peptide alone as siRNA delivery vehicles. The results showed that LPP
complexing siKeap 1 restored Nrf2 antioxidant function, augmented reduction-oxidation homeostasis in the wound area
and accelerated diabetic tissue regeneration.
Although liposomes are a well-studied drug delivery system, its application on transdermal drug delivery is limited
since they are unable to penetrate through the deep layers of skin. The rigid structure of the conventional liposomes
makes them stay in the stratum corneum (SC) layer and achieve low drug delivery efficiency.162 Deformable liposomes,
as a new generation of liposomes, have been developed to overcome this limitation.160 They are generally prepared by
embedding edge activators, such as surfactant and ethanol, into traditional liposomes, which can destabilize the original
lipid layers to achieve a flexible membrane. With a high flexibility, deformable liposomes can change the homeostasis of
the cells in the stratum corneum and squeeze into the deeper viable epidermis.163,164
Polymeric Nanoparticles
Polymeric NPs are colloidal systems that are biocompatible and have simple formulation parameters.165 Drugs embedded
or conjugated with biodegradable polymers can achieve lower degradation rates and release in a controlled manner in the
wound area. These merits make polymeric nanoparticles draw increasing attention in the nano-drug delivery system
field.166 Polymeric nanoparticles possess a core-shell structure with drugs encapsulated in the core and hydrophilic
polymeric outer surface which provides stearic stability.167 Currently, the preparation of polymeric nanoparticles is
majorly based on polylactic-co-glycolic acid (PLGA), polyglycolic acid and other synthetic polymers, as well as natural
polymers (alginate, gelatin, chitosan, etc.).168
To overcome the low solubility and the high susceptibility to oxidation of melatonin, Lopes et al169 incorporated
melatonin into a lecithin-chitosan nanoparticles for diabetic wound healing. The particle size of MEL-NPs was within
proper nanoscale (160 nm), and the therapeutic melatonin was efficiently entrapped in the nanocarrier. The study
concluded that the MEL-NPs delivery system can improve pharmacokinetics of melatonin, thus promotes the vascular
system and accelerates re-epithelization and angiogenesis. Polymeric nanoparticles obtain a low viscosity and dispersion
ability due to their intrinsic structure, which makes them unsuitable candidates for topical administration. To ease the
application of polymeric nanoparticles on topical treatment, Bairagi et al170 have developed ferulic acid nanoparticles and
converted the nano-system into hydrogel. The ferulic acid with antidiabetic and antioxidant properties was encapsuled in
PLGA by nano precipitation method, and then the drug-loaded NPs were mixed into hydrogel for topical treatment. The
results showed that diabetic wounds treated with FA loaded polymeric nanoparticles achieve faster epithelialization,
significantly increasing hydroxyproline content. It is confirmed that FA-PLGA nanoparticles overcome the pharmacoki
netic limitations of FA and significantly promote diabetic wound healing.
Inorganic Nanoparticles
The main component of inorganic nanoparticles are inorganic materials, and inorganic substances include metal, carbon
and ceramics.165 Benefiting from various inorganic components and the nanoscale structure, inorganic NPs exhibit better
biological behaviors than their macroscale counterparts. Many inorganic NPs achieve great success in antitumor therapy,
which highlights their promise in nanomedicine. Therefore, a diverse array of inorganic NPs system has been studied to
explore their prospect in the field of diabetic wound treatment.
Quercetin (QCT) is known as free radical scavenger and anti-inflammatory agent, and AgNPs are effective anti
microbial agents. To investigate the synergistic therapeutic performance of QCT and AgNPs, Badhwar et al171 fabricated
QCT loaded Ag nanoparticles and subsequently hybridized the QCT-AgNPs into hydrogel matrices for diabetic wound
treatment. Compared with marked Ag-loaded dressings, QCT-AgNPs revealed superior therapeutic efficiency in killing
S. aureus and E. coli and reducing oxidative stress. The histopathological evaluation showed that QCT-AgNPs could
significantly reduce the wound gap and promote migration of keratinocytes in DFU models in vivo. Some NDDSs
formulations have focused on the synergistic effect of both the inorganic nanoparticles and the encapsulated drugs. Kaur
et al172 fabricated AgNPs loading with insulin to achieve a mutually reinforcing effect of the two components. The
IAgNPs exhibited appropriate nano size and structure. When applied to diabetic wounds, it notably stimulated healing
activity, which could be explained by downregulating pro-inflammatory factors (IL-6, TNFα) levels at the injured site

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Figure 4 Schematic diagram of wound healing by nano-insulin formulation (IAgNPs). IAgNPs accelerated the wound healing in diabetic conditions by inhibiting pro-
inflammatory cytokines and activating anti-inflammatory cytokines.
Notes: Reprinted from Nanomedicine, 15(1), Kaur P, Sharma AK, Nag D, et al. Novel nano-insulin formulation modulates cytokine secretion and remodeling to accelerate
diabetic wound healing. 47–57, Copyright 2019, with permission from Elsevier.172
(Figure 4). Researchers are extending their studies to the blending application of various types of NPs systems to achieve
multi-functionality. Choudhary et al173 developed chitosan-based hydrogel co-encapsulated with fresh blood and nano
particles (Ca-AlgNps and AgNPs) for diabetic wound healing. The co-encapsulated nanocarrier contributes to much
higher closure rate, the Chitosan/Ca-AlgNps/AgNPs hydrogel exhibiting a higher closure rate then separate AlgNps or
AgNPs loaded hydrogels. The antimicrobial studies confirmed that Chitosan/Ca-AlgNps/AgNPs hydrogel has broad
spectrum antibacterial properties. All the evidence supported that Chitosan/Ca-AlgNps/AgNPs hydrogel might become
a potential candidate for diabetic wound healing.
Lipid Nanoparticles
Lipid nanoparticles were generally synthesized by glycerophospholipids, cationic lipids, sterol lipids and PEGylated
lipids coated with oligonucleotides.174 Solid lipid nanoparticles (SLNs) and nanostructured lipid carriers (NLCs) are two
representatives of LNPs, and both of them can increase solubility and stability of encapsulating drugs.175 Recently,
researchers have had great interest in application of LNPs in topical treatment.
Arantes et al176 fabricated SLNs loading with retinoic acid to reduce adverse reactions of the all-trans retinoic acid.
The SLN-ATRA were developed through a hot melting homogenization method, and based on the optimized method,
SLN-ATRA can be prepared without organic solvents and achieve high encapsulation rate and lower polydispersity index
(PDI). The results showed that the SLN-ATRA had superior ability to free ATRA in reducing leukocyte infiltration and
accelerating wound closure, collagen deposition and reducing scar tissue when applied on excisional wounds of diabetic
mice. In another scientific report, pioglitazone-loaded LNPs were designed, fabricated, then successfully encapsulated
into a collagen/chitosan (COL-CS) scaffold.177 This scaffold possessed optimum porosity, high encapsulation efficiency
and low degradation rate. When applied in full-thickness diabetic wounds, it significantly improved the wound contrac
tion rate, and the data of enzyme-linked immunosorbent assay indicated the MMP9 level is decreased. Sun et al178
reported 20 (S)-protopanaxadiol-loaded nanostructured lipid carriers were successfully incorporated in a silicone elas
tomer. The results showed that the formulation exhibited remarkable in vitro anti-inflammatory and proangiogenic
activity. When applied to diabetic mice with chronic non-healing wounds, it notably achieves an ordered recovery

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through suppressing inflammatory infiltration, promoting angiogenesis and increasing collagen deposition. Huseh et al92
designed and synthesized nanostructured lipid carrier formulations encapsulating recombinant human thrombomodulin
(rhTM) for diabetic wound healing. RhTM-loaded NLCs were characterized by much higher encapsulation efficiency and
exhibited a controlled drug release behavior for more than 72 h. The in vitro study showed that rhTM-NLC could induce
cell migration of keratinocyte cells to promote SC formation. Therefore, this formulation may warrant promising delivery
systems for diabetic wound healing. However, LNP systems also have several disadvantages, such as low drug loading
and biodistribution, which lead to high uptake to the liver and spleen and limit their application in clinical trials.179
Nanofibers
Nanofibers comprise an important class of nanomaterials, and generally have a diameter less than 100 nm.180 Nanofibers
provide many remarkable properties such as large surface area, variable porous rate, great flexibility in selecting
materials, and fine fabrication technology.181 These wonderful features make nanofibers a potential candidate for
biomedical application, especially in drug delivery. Electrospinning, as a simple and versatile method, is widely used
to format nanofibers.182 There are a wide range of drugs that can be incorporated into nanofibers, including antibiotics,
proteins, DNA, RNA and growth factors.183 Electrospun nanofibers can achieve high surface to volume ratio, and have
different controlled drug release profiles.182,184
Agarwal et al185 prepared curcumin-loaded silk fibroin and combined this nanofiber with polycaprolactone (PVC) and
polyvinyl alcohol (PVA) via electrospinning nanotechnology. This nanofiber showed rapid healing efficacy in
a streptozotocin-induced diabetic mice wound model. Also, data of the histopathological studies revealed that in vivo
the normal skin structure and tissue arrangement were restored in NDDSs-treated group.
Liu et al186 electrospun sesamol into cellulose acetate-zein (CA/zein) nanofiber membranes to fabricate efficient
vehicles for cutaneous wound healing. In vivo observation depicted significant stimulation of myofibroblasts via
activating TGF-β signaling pathway transduction. The nanofiber membranes also downregulated inflammatory factors
(IL-1β, TNF-α, NOS2) levels and upregulated IL-6 secretion, which promotes keratinocyte growth, and thus
enhances wound healing. In some cases, nanofibers were combined with stem cell therapy; Chen et al106 reported
BMSCs-laden 3D scaffolds for a personalized diabetic wound treatment. The 3D scaffolds were electrospun with radially
or vertically aligned nanofibers to achieve customizable structures to fit different wounds. The results showed that this
nanofiber scaffold can replace damaged skin and act as a temporary barrier and has good biodegradability. Thus, these
scaffolds were regarded as a potential customizable platform for managing diabetic wounds. Lee et al187 developed
insulin-loaded PLGA scaffolds via coaxial electrospinning (Figure 5). The core-shell nanofibrous scaffolds were
confirmed to feature with better biodegradability, hydrophilicity and water-containing capacity. In vivo study showed
Figure 5 Accelerate the healing wound following treatment using functionally active insulin released from insulin-loaded nanofibrous scaffolds.
Notes: Reprinted from Nanomedicine, 24, Lee CH, Hung KC, Hsieh MJ, et al. Core-shell insulin-loaded nanofibrous scaffolds for repairing diabetic wounds. 102123,
Copyright 2020, with permission from Elsevier.187

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that this core-shell nanofiber affects TGF-β expression and promotes diabetic wound repair. Nanofibers delivering more
than one drug draw increasing attention as a potential substrate for biomedical application, especially in diabetic wound
healing fields. Dwivedi et al66 reported a novel nanofiber scaffold, which carried the antibiotic agent gentamicin sulfate
(GS) and rhEGF. The results of scanning electron microscopy, Fourier transform infrared spectroscopy and X-ray
diffraction confirmed that GS was successfully loaded into scaffolds and the rhEGF was covalently immobilized on
the surface of the nanofiber scaffolds. In vivo work found that the nano-scaffolds induced faster reepithelialization
activity in dorsal wounds of diabetic mice. According to the report of Lee et al,188 nanofibrous scaffolds were developed
with poly(lactide-co-glycolide) (PLGA) loaded with bioactive antibiotics and platelet-derived growth factor (PDGF), and
the scaffolds obtained a coaxial sheath-core architecture. The nano-scaffolds were characterized with excellent biocom
patibility, and sustainably released vancomycin, gentamicin and growth factor for over 3 weeks. Furthermore, reduced
phosphatase and tensin homolog content and enhanced angiogenesis marker (CD31) were detected to provide evidence
for benefiting infected diabetic wound healing.
Nanohydrogel
Nanohydrogel is a multicomponent system composed of a polymeric three-dimensional network and water.189,190 The
porous structure endows nanohydrogels with the ability of rapidly swelling and retaining large amounts of water.167 In
recent years, various hydrogel products have been designed in application of drug delivery for accelerating diabetic
wound healing.191 Nanohydrogel provides a moist environment for the wound area, and with soft texture and suitable
mechanical strength, it provides a beneficial environment for wound healing.69,192
Zhang et al193 introduced a polyvinyl alcohol (PVA)/alginate (Alg) nanohydrogel encapsulating HUCMSCs-derived
exosomes to regulate diabetic wound healing (Figure 6). The results showed that the nanohydrogel significantly
facilitates the proliferation, migration and angiogenesis of HUVECs and affects wound healing related molecules
(SMA, SR-B1 and CD31). Further investigation revealed that this novel formation accelerated wound healing via
regulating ERK1/2 pathway, and thus promoting angiogenesis. A multifunctional hydrogel was reported by Xiong et al194
Figure 6 The schematic diagram of the method of making exo@H and the process that exosomes were applied to the wound area and promoted wound healing.
Notes: Reprinted from Mater Sci Eng C Mater Biol Appl, 120, Zhang Y, Zhang P, Gao X, Chang L, Chen Z, Mei X. Preparation of exosomes encapsulated nanohydrogel for
accelerating wound healing of diabetic rats by promoting angiogenesis. 111671, Copyright (2021), with permission from Elsevier.193

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to accelerate oxidative diabetic wound healing. This HA-based hydrogel consisted of MnO2/ε-PL nanosheet, FGF-2 and
M2-derived exosomes (M2 Exos). With the addition of MnO2, this nanocomposite eliminates excess H2O2 production
and provides O2 for the wound site. Moreover, specially encapsulated FGF-2 and M2 Exos respectively promote
angiogenesis and epithelization. Thus, this hydrogel could be a viable nano-biomaterial for chronic diabetic wound
repair. Nidadavolu et al195 designed a novel peptide-based hydrogel, using nanotechnology to self-assemble valsartan
amphiphiles into a filamentous structure (val-filaments). The results of in vivo observation showed the nanohydrogel
provided a localized and sustained release of valsartan amphiphiles over 24 days. Moreover, this scaffold downregulated
Tgf-β signaling pathway mediators (pSmad2, pSmad3 and Smad4) and increased mitochondrial metabolic pathway
intermediates.
Discussion
The treatment of diabetic wounds faces many challenges and new insights are needed in this field. Drug delivery system
combined with nanotechnology and biomaterials offers a rich toolbox for the treatment of complex pathophysiology of
diabetic wound and tissue repair. In this review, we summarized pathology progress of diabetic wound healing, loading
substances of NDDSs and loading systems of NDDSs.
Most of the encapsulated drugs are subject to impaired function of different cells and unbalanced levels of key
healing mediator. The understanding of specific molecules function in diabetic wound healing progress facilitates the
design of drug delivery systems. However, the etiopathogenesis of diabetic ulcers is diverse and complex, the confirmed
positive effect of one therapy on one model might have no effect on other models or individuals.
Recently, novel NDDSs, such as liposomes, nanoparticles, nanofibers and nano-hydrogels loaded with bioactive
molecules and non-bioactive elements, have been reported and these studies confirmed NDDSs with therapeutic
substances benefit diabetic wound healing. In this context, various smart nano hydrogel system have been investigated,
but few of them mention the interactive effect between the carrier and the cargo and horizontal comparison with other
types of systems. So, there is still no confirmed conclusion of which system performs the best.
To date, various in vitro and in vivo studies have demonstrated the great therapeutic potential of NDDSs, while most
of them illustrate treatment benefits through animal models. Few studies, however, consider the irregular shape and
different depths of wounds in clinical patients; the animal models usually include only one condition.
Although there are large numbers of studies focusing on therapeutic potential of NDDSs, effective management of
diabetic wound healing remains insufficient. Depending on the current gaps above, researchers need to pay more
attention to factors in different angles. First, as in diabetic patients, people develop chronic non-healing wounds often
accompanied with unregulated hyperglycaemia and vascular lesions. The ideal NDDSs should load drugs which can
ameliorate the basic diabetic pathological conditions, besides drugs that directly accelerate wound healing processes.
Also, the interaction between carried drugs and pathological stages should be clearly clarified. Since there is no single
substance that can perform best and suits all kind of diabetic wound conditions, future studies should focus on multi-drug
systems to provide synergic effects at different stages, especially the application of gene therapy for precise treatment.
The methods of NDDSs preparation are also important, so, researchers should build systems with more simple methods
for manufacturing and marketing. To complete clinical translation, more preclinical and clinical studies on the benefit on
humans should be carried out.
Conclusion
Today, the treatment of diabetic non-healing wounds faces many difficulties. The complex pathological process of
diabetic wound healing and various conditions of diabetic patients create obstacles to current treatment results. Many
therapeutic agents (GFs, genes, stem cells, drugs, metal ions and oxygen) related to healing stages and mechanisms have
been studied to make an equilibrium level of key mediator for better wound healing. The field of drug delivery
systems has shown great performance in delivering therapeutic drugs for diabetic wound treatment. Over the past few
years, nanomedicine has facilitated the development of drug delivery systems, and various nano-drug delivery
systems (liposomes, NPs, nanofibers and nanohydrogel) have been formed to deal with diabetic non-healing wounds.

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Overall, the nano-drug delivery system with therapeutic agents can accurately provide agents to the wound site and
achieve great therapeutic potential for diabetic wound management.
Abbreviations
DM, diabetes mellitus; DDSs, drug delivery systems; NDDs, nano-drug delivery systems; DFU, diabetic foot ulceration;
HBO, hyperbaric oxygen therapy; PCL, polycaprolactone; GelMA, Methacrylate Gelatin; GF, growth factor; ECM,
extracellular matrix; MMP, matrix metalloprotein; DN, diabetic neuropathy; PAD, peripheral arterial disease; IDSA,
Infectious Diseases Society of America; TGF-β, transforming growth factor-β; VEGF, vascular endothelial growth factor;
VEGFR, vascular endothelial growth factor receptors; PDGF, platelet-derived growth factor; EGF, epidermal growth
factor; FGF, fibroblast growth factor; miRNAs, microRNAs; siRNA, small interfering RNA; RNAi, RNA interference;
MSCs, mesenchymal stem cells; ADSCs, adipose-derived stem cells; hUCMSC-exos, umbilical cord-derived mesench
ymal stem cell-derived exosomes; CNPs, Cur nanoparticles; GMs, gelatin microspheres; HA, hyaluronic acid; SPC,
sodium percarbonate; ROS, reactive oxygen species; NO, nitric oxide; LPP, lipoproteoplex; CLN, cationic lipid
nanoparticle; SC, stratum corneum; PLGA, polylactic-co-glycolic acid; QCT, quercetin; SLNs, solid lipid nanoparticles;
NLCs, nanostructured lipid carriers; rhTM, recombinant human thrombomodulin; PVC, polycaprolactone; PVA, poly
vinyl alcohol.
Acknowledgments
We acknowledge funding by the National Key R&D Program of China [No. 2018YFE0194300], the Natural Science
Foundation of Guangdong Province [No. 2020A1515010107], the Guangdong Province Key Field R&D Program Project
[No. 2020B1111150001], and the Science and Technology Innovation Project of Guangdong Province
[No. 2018KJYZ005]. We acknowledge Mr Yanbin Gao, Dr Jun Ma for their supervision of this article.
Disclosure
The authors report no conflicts of interest in this work.
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Open Access Full Text Article

Recent Advances in Nano-Drug Delivery

International Journal of Nanomedicine 2023:18 1537–1560 1537

Wound Healing Pathophysiology

1538 https://doi.org/10.2147/IJN.S395438 International Journal of Nanomedicine 2023:18

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Diabetic Wound Healing

Current Diabetic Wound Treatment

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Treatment of Wound Infection

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Table 1 Delivery of Growth Factors with Nanocarriers

PDGF-BB Nanohydrogel Destruct biofilm. Destruct the biofilm; keep [70]

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Table 2 Delivery of Genes/Proteins/Peptides with Nanocarriers for Diabetic Wound Healing

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Cargos Carriers Functions Refs.

LncRNA-H19 High-yield extracellular vesicle-mimetic Neutralize the regeneration-inhibiting effect of [85]

P311 peptides Micelles Ros-trigged P311 release to reduce oxidative [94]

CCN1 Nanoformulation Increase CCN1 intracellular expression, decreses [95]

PDGF-BB proteins Fibrin-based hydrogel Induce angiogenesis and arteriogenesis. [88]

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Table 3 Stem Cell/Exosomes Loading Nanomaterial for Diabetic Wounds

ADSCs Injectable hydrogels Promise regenerative capabilities; STZ-induced mice [101,102]

hFDSPC HA Improve re-epithelialization, STZ-induced mice [110]

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Table 4 Delivery of Drugs for Efficient Diabetic Wound Healing

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Table 5 Delivering Oxygen/NO for Diabetic Wound Treatment

Oxygen Microspheres Augment the survival and migration of [144]

Calcium peroxide OxOBand Facilitate faster wound closure, enhance [145]

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Materials Carriers Functions Refs.

QCN oxygen Nanoemulsion (NE) Accelerate wound-healing. [116]

Perfluorocarbon emulsions Chitosan nanoparticles Alleviate hypoxia conditions on diabetic [67]

S-Nitroso- Hitosan/polyvinyl-alcohol hydroge; GelMA Continuous cell-proliferating activity; speed up [148,149]

ZnO Nanofibers Sustained release two bioactive agents. [154]

Nano-Drug Delivery System

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1550 https://doi.org/10.2147/IJN.S395438 International Journal of Nanomedicine 2023:18

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1552 https://doi.org/10.2147/IJN.S395438 International Journal of Nanomedicine 2023:18