Impaired wound healing in diabetes: the rationale for clinical use of hyaluronic acid plus silver sulfadiazine.

Diabetes-related chronic cutaneous lesions are a serious and common problem, as well as a major cause for hospital admissions, although no general consensus has been reached on the best available treatment for this frequent pathological condition. The primary objective of this review is to analyze the most recent evidence supporting the clinical use of a formulation containing hyaluronic acid (HA) and silver sulfadiazine (SSD) in the diabetic patient. This formulation has been widely used in cutaneous lesions of various etiology, both acute and chronic. The mechanisms underlying tissue repair are altered in the diabetic patient with respect to a healthy individual, namely for a diminished response of the keratinocytes and a reduced capacity of the endothelial cells to form new vessels (neoangiogenesis). Since HA favours the tissue repair process through various mechanisms, among these an increased angiogenic response and an activation of the keratinocytes, its application in diabetic lesions is a rational choice. SSD has been widely used in acute cutaneous lesions, particularly in burns, where it is considered the "gold standard" by which other treatments are measured. The efficacy of SSD in terms of antibacterial activity spectrum on various types of microorganisms, with a favourable safety profile, supports the potential use of SSD in diabetic lesions, where the presence of infection caused by bacteria resistant to most available antibiotics, but not to SSD, is rather frequent. In conclusion, the combined use of HA and SSD in the diabetic patient proves a rational choice and is potentially capable of improving the general clinical situation, on the basis of the synergic effect to control infection and accelerate the tissue repair process.