The Journal of Clinical Investigation   R E V I E W S E R I E S : R E PA R AT I V E I M M U N O L O G Y

Series Editors: Hamid Rabb and Franco R. D’Alessio

Innate immune cell–epithelial crosstalk

during wound repair
Jennifer C. Brazil, Miguel Quiros, Asma Nusrat, and Charles A. Parkos
Department of Pathology, University of Michigan, Ann Arbor, Michigan, USA.

Skin and intestinal epithelial barriers play a pivotal role in protecting underlying tissues from harsh external environments.
The protective role of these epithelia is, in part, dependent on a remarkable capacity to restore barrier function and tissue
homeostasis after injury. In response to damage, epithelial wounds repair by a series of events that integrate epithelial
responses with those of resident and infiltrating immune cells including neutrophils and monocytes/macrophages.
Compromise of this complex interplay predisposes to development of chronic nonhealing wounds, contributing to morbidity
and mortality of many diseases. Improved understanding of crosstalk between epithelial and immune cells during wound
repair is necessary for development of better pro-resolving strategies to treat debilitating complications of disorders ranging
from inflammatory bowel disease to diabetes. In this Review we focus on epithelial and innate immune cell interactions that
mediate wound healing and restoration of tissue homeostasis in the skin and intestine.

Introduction Like mucosal wound repair in the gut, superficial epidermal

Epithelial barriers at mucosal and dermal surfaces form a protec- injuries of the skin such as first-degree burns do not undergo
tive shield against microbial invasion and environmental dam- major remodeling during healing and usually do not produce scar-
age. Perpetual epithelial renewal is facilitated by stem and pro- ring. However, deeper transdermal injuries heal with consider-
genitor cells that balance proliferation and differentiation signals able remodeling, often resulting in fibrosis, permanent scarring,
to continuously replace terminally differentiated or dying cells. and loss of skin appendages including hair follicles and sebaceous
Rapid self-renewal also supports epithelial cells’ essential role in glands. Failure to resolve cutaneous wounds, formation of chron-
barrier regulation and wound repair. Wound healing is a complex ic ulcers, and excessive scarring represent appreciable health and
process characterized by four overlapping stages: hemostasis, economic burdens to individuals with a number of conditions,
inflammation, proliferation/re-epithelization, and remodeling. including vascular insufficiency caused by factors such as aging,
Dysregulation of any stage is linked to an increased risk of devel- diabetes mellitus, and smoking (5).
oping chronic nonhealing wounds, representing a substantial Given the devastating impact of defective intestinal and der-
worldwide health care burden associated with considerable mor- mal wound healing on human health, this Review highlights cur-
bidity and mortality (1, 2). rent mechanisms regulating epithelial wound repair, focusing on
During normal gut function, the mucosal epithelium is repet- the intestine as a well-studied example of a simple columnar epi-
itively injured through mechanical and chemical interactions thelium and the skin as an example of a more complicated strati-
with luminal contents. Mucosal injuries are constantly repaired to fied epithelium. As other Reviews in this JCI series discuss adap-
maintain gut homeostasis and provide sufficient nutrients while tive immune responses, we limit discussion to the role of epithelial
simultaneously preserving barrier function. Typically, superficial and innate immune cell interactions in wound healing. We discuss
mucosal damage is associated with acute intestinal inflammation roles of epithelial cells, neutrophils, monocytes, and macrophages
that resolves quickly without substantial fibrosis or compromised in wound repair and address interactions between these cell types.
gastrointestinal function. However, chronic disorders of the diges-
tive tract such as inflammatory bowel disease (IBD; encompassing Epithelial cells in cutaneous and intestinal
Crohn’s disease and ulcerative colitis) are characterized by recurring wound repair
mucosal inflammation and injury (reviewed in ref. 3). While IBD eti- Intestinal epithelium. The intestinal epithelium lines the largest
ology remains elusive, its pathobiology is closely linked to dysreg- mucosal surface in the body and provides critical barrier between
ulated intestinal barrier function and insufficient healing, which is microbiota and mucosal immune cells. The initial response to
associated with perturbed mucosal homeostasis (4). Approximately intestinal epithelial injury involves hemostasis, which limits blood
3 million individuals in the United States suffer from IBD (1). loss and seals damaged tissue. With the onset of hemostasis, the
inflammatory response begins and includes critical contributions
from epithelial and immune cells. In vitro and in vivo studies of
Authorship note: JCB and MQ contributed equally to this work.
human, rabbit, and rodent epithelia reveal that within minutes of
Conflict of interest: The authors have declared that no conflict of interest exists.
Copyright: © 2019, American Society for Clinical Investigation.
intestinal mucosal injury, epithelial cells within crypts adjacent to
Reference information: J Clin Invest. 2019;129(8):2983–2993. the wound begin migrating as a collective sheet to cover injured/
https://doi.org/10.1172/JCI124618. denuded surfaces (6–10). During repair, epithelial cells under-

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Figure 1. Epithelial reparative triggers and

events. Cytokines, growth factors, Wnt
ligands, SPMs, and MMPs released in the
wound microenvironment in response to injury
support epithelial cell proliferation as well as
migration. Dynamic remodeling of focal adhe-
sion complexes and actin promotes interac-
tions with the ECM that facilitate the epithelial
sheet’s migration. Following initial epithelial
cell migration, keratinocytes peripheral to the
leading edge proliferate and mature to restore
epithelial barrier homeostasis and function.

go morphologic changes in shape, modify cell-cell contacts, and degrade ECM components. Humans express 24 MMPs that regu-
migrate collectively to reseal the barrier. late diverse activities important for ECM remodeling and forward
Collective epithelial cell migration during wound healing movement of the epithelium (reviewed in ref. 19). MMP endopro-
requires cytoskeletal remodeling and active crosstalk between teinase activity facilitates removal of disorganized structural pro-
cell matrix and cell-cell junction proteins. To facilitate migration, teins from healing wounds to make room for newly synthesized
integrin-containing focal adhesive complexes are dynamically collagen. Furthermore, MMP-mediated conversion of type III
remodeled in concert with intracellular F-actin–rich extrusions at collagen to more stable type I collagen increases wound tensile
the leading edge that adhere to the extracellular matrix (ECM) to strength. Fibroblast- and keratinocyte-derived MMP-1 promotes
propel epithelial sheet migration (Figure 1 and refs. 11, 12). breakdown of excess collagen in murine and rabbit models of
Dermal epithelium. In contrast to the single layer of columnar skin repair (20–22). Though not expressed in skin, epithelial cell–
epithelial cells lining the gut, a multilayered squamous epithelium derived matrilysin (MMP-7) is reportedly the key MMP involved in
lines the skin. Dermal epithelial cells form an important physical repairing injured intestinal mucosa in humans (23, 24).
barrier against the environment, protecting against pathogens, Signals that trigger epithelial migration and proliferation from
xenobiotics, and dehydration (13, 14). Like intestinal epithelium, injured sites are incompletely understood. Loss or modification
a reservoir of dynamic basal stem cells capable of generating all in cell-cell contact and release of intracellular molecules initiates
skin cell lineages facilitates ongoing cutaneous tissue turnover repair (25). These events set the stage for recruiting leukocytes
and skin regeneration (15, 16). The outermost epidermal layer and mesenchymal cells that orchestrate wound repair. Formylat-
comprises multiple layers of flattened dead cells (stratum corne- ed peptides and ATP released by damaged cells, also referred to
um), making skin highly impermeable. However, skin epidermis as damage-associated molecular patterns (DAMPs), orchestrate
interfaces with the outside world, making it particularly prone to repair by promoting epithelial cell migration and proliferation.
injury, necessitating frequent repair. Epithelial wounds are also a source of intracellular Ca++ waves
Like repair of mucosal wounds, repair of skin injury depends that are rapidly transmitted into surrounding tissues to influence
on activation of the coagulation cascade followed by immune cell repair. Furthermore, ROS signaling and wound-associated phys-
infiltration of wounds, contributing to protection against invading ical cues influence epithelial repair. Small GTPases in the Rho
pathogens and epithelial repair (17). As in the intestine, skin re- family regulate remodeling of F-actin, intercellular junctions, and
epithelization also involves collective migration of keratinocytes cell-matrix adhesions (26) and are crucial for epithelial cell migra-
across the injured dermis. Following initial epithelial cell migra- tion and wound sealing. Similarly, the Rho GTPase Rac1 promotes
tion, keratinocytes behind the leading edge proliferate and mature intestinal epithelial proliferation by targeting β1-integrin in cellu-
to restore epithelial barrier function. Using whole-mount epider- lar protrusions and modulating actin dynamics (26).
mis, Aragona et al. confirmed the existence of leading-edge, non- Reparative signaling events are also regulated by extracellular
proliferative migrating cells and a proliferative hub of stem cells mediators in the epithelial milieu, including annexin A1, annexin
and their progeny (16), highlighting molecular signatures associ- A2, and serum amyloid A1, which have been shown to influence
ated with these two distinct epidermal compartments. Upon re- integrin localization, focal adhesion kinase activation, and cell
epithelization, new highly vascularized connective tissue contain- matrix remodeling in mouse and human intestinal mucosa (27–30).
ing fibroblasts, granulocytes, macrophages, and loosely organized After injury, chemokines/cytokines and growth factors play crucial
extracellular collagen is deposited into the wound bed. The final roles in epithelial c­ell adhesion, migration, proliferation, and dif-
stage of skin wound repair involves tissue remodeling that begins ferentiation. TGF-β–dependent signaling pathways mediate the
2 to 3 weeks following initial injury and lasts up to a year or more, regulatory effects of many repair mediators, including PDGF, EGF,
depending on wound severity (18). VEGF, IL-1, IL-2, IL-6, and IFN-γ (6). Canonical and noncanonical
Epithelial repair signaling. During wound remodeling in Wnt proteins also modulate epithelial wound repair. A recent in
the skin and gut, matrix metalloproteinases (MMPs) cleave or vivo study revealed a role of Wnt5a in orchestrating colonic crypt

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regeneration via TGF-β signaling (31). In addition, while tradi- junction proteins including E-cadherin, promoting epithelial
tionally considered a proinflammatory cytokine, recent evidence mobility and barrier restitution following injury in vitro and in
demonstrated that TNF-α promotes mucosal wound repair in mice vivo (52, 53). HIF-1α also promotes transcriptional upregulation
by activating Wnt/β-catenin signaling, increasing epithelial cell of genes that enhance cutaneous wound repair, including meta-
proliferation, and upregulating expression of receptors that pro- bolic proteins, adhesion proteins, soluble growth factors (TGF-β
mote intestinal healing (Figure 1 and refs. 32, 33). and VEGF), and ECM components (54, 55). Therefore, neutro-
In summary, intestinal and cutaneous wound repair is in part phil-mediated HIF-1α stabilization in wound microenvironments
facilitated by remarkable migratory and proliferative capabilities acts through epithelial cells to promote barrier restitution and a
of epithelial cells. In the following sections, we highlight the com- faster return to tissue homeostasis.
plex spatial and temporal interplay between wound-associated In addition to eliminating microbes and modulating the
neutrophils, monocytes, and macrophages as well as the crosstalk wound microenvironment through oxygen metabolism, neutro-
between these innate immune cells and dermal and intestinal epi- phils release pro-repair cytokines, chemokines, and growth factors
thelial cells during tissue repair. that signal through wound-associated immune and epithelial cells
to promote healing. Following mucosal damage, infiltrating neu-
Innate immune cells in intestinal and trophils secrete TGF-β to activate MEK1/2 signaling and induce
dermal repair intestinal epithelial cell–mediated production of the EGF-like
Neutrophils. Neutrophils are the first immune cells to infiltrate molecule amphiregulin (AREG) (56). AREG promotes intestinal
wounded tissues, arriving in large numbers in response to DAMPs epithelial cell differentiation and proliferation in a positive man-
released from injured and necrotic cells. Murine neutrophil ner to facilitate efficient return to mucosal homeostasis in vivo
recruitment to wounded tissues begins 4 to 6 hours after initial (56, 57). TGF-β also accelerates re-epithelization, angiogenesis,
injury, with maximum numbers detected after 18 to 24 hours (34, and granulation tissue formation in healing murine and human
35). The neutrophil’s role in wound healing can be viewed as a skin wounds (58–60). However, unlike healing intestinal mucosa,
double-edged sword (36). Too few neutrophils risks infection and neutrophils in skin wounds are not yet identified as an import-
delayed healing (37), whereas overpersistence of neutrophils in ant source of TGF-β. While not implicated in TGF-β production,
injured tissues also delays healing through collateral tissue dam- human neutrophils that migrate into skin wounds upregulate a
age. For example, neutrophils contribute to the crypt loss and transcriptional program that includes chemoattractants (e.g.,
ulceration that are pathological hallmarks of ulcerative colitis, CCL-2 and MIP1α, also known as CCL-3) and genes that promote
and excessive neutrophil infiltration parallels disease severity and angiogenesis (VEGF, IL-8, GRO-γ, and CCL-2), proliferation,
patient symptoms (38–40). Therefore, neutrophil activation and and activation of keratinocytes and fibroblasts (IL-8, IL-1β, and
migration in response to dermal or mucosal injury is tightly reg- CCL-2) (61–63). Moreover, several studies reported that neu-
ulated. Impaired leukocyte trafficking delays cutaneous wound trophils are an important source of de novo TNF-α synthesis in
healing in mice (41, 42), highlighting neutrophils’ critical impor- healing mouse skin lesions (64, 65). While TNF-α is traditionally
tance in orchestrating efficient wound repair. Similarly, neutro- considered a proinflammatory mediator, it also mediates crucial
phil depletion in damaged intestinal mucosa was associated with pro-repair mechanisms, including stimulation of fibroblast prolif-
increased inflammation, impaired intestinal mucosal repair, and eration, re-epithelization, and angiogenesis (66).
slower recovery from colitis in vivo (43, 44). Furthermore, individ- Neutrophils recruited to wounds also respond to the proin-
uals with neutropenia (or deficiencies in neutrophil trafficking or flammatory cytokine–rich milieu by producing CC chemokines
function) display not only higher risk for developing wound infec- such as CCL-20 (67), which attracts CCR-6–expressing inflam-
tions but also impaired wound healing (37, 45, 46). matory monocytes into murine injured skin (68). Recent work
While many previous studies focused on neutrophil trafficking identified tissue-infiltrating neutrophils as a major source of IL-23
(reviewed elsewhere in refs. 47, 48), the DAMP-triggered mecha- in the intestines of individuals with IBD (69). Furthermore, upon
nisms that facilitate neutrophil migration into skin and intestinal stimulation with IL-23 and TNF-α, murine and human colonic
wounds are not yet well described. Once recruited to wound- neutrophils produce IL-22, a member of the IL-10 superfamily
ed dermal or intestinal tissues, neutrophils prevent infection of cytokines. In murine intestinal wounds, neutrophil-produced
by eradicating microbes that enter through disrupted epithelial IL-22 stimulated intestinal epithelial production of AMPs RegIIIβ
barriers. Neutrophils destroy invading microbes through phago- and S100A8 and increased epithelial proliferation, differenti-
cytosis, or sometimes NETosis (formation of extracellular traps; ation, and migration (70–72). Intestinal injury induces another
ref. 49), while releasing antimicrobial peptides (AMPs, including IL-1 family member, IL-36, in epithelial cells and macrophages,
cathelicidins and β-defensins), ROS, and cytotoxic enzymes such and signaling through IL-36R promotes neutrophil recruitment,
as elastase and myeloperoxidase (Figure 2 and ref. 50). To pro- IL-22 production, and murine intestinal epithelial repair (73). In
duce microbicidal ROS, neutrophils consume large amounts of murine skin, it is known that IL-22 mediates interactions between
oxygen, generating a hypoxic microenvironment within wound- immune cells and fibroblasts to promote wound healing (74, 75).
ed tissues that results in stabilization of the transcription factor However, murine neutrophils have not yet been identified as a
HIF-1α in human and murine intestinal mucosa (51, 52). In wound- prominent source of IL-22 during skin repair.
ed intestinal mucosa, HIF-1α stabilization results in enhanced epi- An additional mechanism whereby neutrophil-epithelial
thelial expression of intestinal trefoil factor (ITF). ITF activates crosstalk promotes mucosal wound healing is via production of
epithelial MAPK signaling and induces reorganization of cell-cell chemical mediators, including diadenosine triphosphate (Ap3A).

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Figure 2. Proinflammatory stage of wound healing. Neutrophils are the first responders to epithelial injury. They clear bacteria present at the wound site,
limiting infection, and secrete proinflammatory TNF-α, which stimulates fibroblast proliferation and angiogenesis.

Human colonic epithelial cells metabolize neutrophil-produced selectively deplete inflammatory neutrophil populations from
Ap3A to adenosine, resulting in downstream activation of surface poorly healing cutaneous and intestinal wounds. Additional stud-
adenosine receptors and enhanced epithelial barrier function and ies are needed to identify markers and develop antibodies and
mucosal wound-healing responses in the gut (76, 77). In the muco- small-molecule inhibitors that specifically target inflammatory
sa, neutrophil-derived adenosine signals primarily through cAMP neutrophils in wounds to promote repair and reduce chronic tissue
(78), which increases expression of human epithelial tight junction damage in the skin and gut.
proteins including ZO-1 and occludin and modulates actin and Monocytes. Following the initial neutrophil wound influx,
intermediate filament dynamics (79). Like its pro-repair effects epithelial, endothelial, lamina propria, and infiltrating immune
in the intestine, topical application of adenosine promotes cuta- cells release chemokines including CCL-20 and CCL-2 (84).
neous wound healing by stimulating angiogenesis and suppress- These mediators facilitate subsequent recruitment of circulat-
ing inflammatory cell function in mice (80). However, no direct ing monocytes into sites of tissue damage (Figure 2 and ref. 85).
effects of neutrophil-derived adenosine on skin epithelia have Wound-infiltrated monocytes play crucial roles in orchestrating
been reported to date. Taken together, these studies highlight the tissue repair, including regulating angiogenesis, clearing cellu-
range of neutrophil-produced mediators acting on epithelial cells lar debris, and recruiting additional immune cells. Monocytes
and wound-associated immune cells to promote cutaneous and recruited into wounded tissues further differentiate into macro-
intestinal wound healing. phages and/or DCs. In murine wounds, chemokines including
The above evidence highlights the dual roles of wound- CCL-2 and CX3CL-1 and their respective receptors, CCR-2 and
associated neutrophils that were once thought to simply maintain CX3CR-1, regulate monocyte recruitment. Previous studies show
sterility following injury to include crucial immunomodulatory that CX3CR-1 and CCR-2 are essential for wound repair in vivo:
and pro-resolving or wound-healing functions. Further develop- Cx3cr-1–null mice have delayed healing in skin wounds, and inhib-
ment of sophisticated imaging methodology including intravital iting CX3CR-1 signaling decreases skin angiogenesis and wound
microscopy (81) combined with transgenic strategies that specifi- repair (86). In the gut, Ly6Chi monocyte recruitment requires
cally target/label neutrophil subsets in vivo (82) will allow detailed CCR-2, and CCR-2–deficient mice have reduced numbers of
mechanistic analyses of neutrophil behavior within wound-heal- monocyte-derived macrophages in wounds (87). Other ligands/
ing environments. Furthermore, recent advances in understand- receptors involved in monocyte trafficking include CCR-1/CCL-3,
ing neutrophil plasticity and identifying distinct neutrophil sub- CCR-5/CCL-5, CCR-6/CCL-20, CCR-7/CCL-19, and CCR-8/
sets (83) should be exploited to develop therapeutic strategies to CCL-1 (reviewed in ref. 88).

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Figure 3. Resolution of inflammation and repair. Regenerating epithelial cells express pro-repair molecules including CCL-2, COX2, LGF1, and IL-11, possibly
as a result of their activation by TRMs. Wound-associated macrophages (WAMs) and neutrophils also produce pro-repair signals, including annexin A1,
VEGF-A, TGF-β, IL-10, and SPMs, that enhance resolution of inflammation at the wound site. In addition to supporting epithelial repair and migration,
these pro-repair signals polarize macrophages to M2-like phenotypes that clear apoptotic neutrophils. In the presence of SPMs, neutrophil-derived micro-
particles may serve as a negative feedback mechanism to suppress additional neutrophil recruitment. TGF-β also stimulates fibroblast differentiation into
myofibroblasts, which produce collagen that provides structural support to the healing epithelium.

Interestingly, in mice, some monocytes that leave the circu- Both healthy intestine and skin contain resident monocyte-
lation to migrate into injured tissues do not differentiate into tis- derived macrophages (90). Given that skin and intestinal epithelia
sue macrophages or DCs but instead undergo apoptosis and are are constantly exposed to microorganisms and their products, it
removed from wound sites. Before removal, these monocytes follows that there is a dynamically changing population of associ-
contribute to wound-healing responses by releasing cytokines and ated macrophages. Continuous exposure to commensal microor-
chemokines (88). Tissue-infiltrating monocytes can have inflam- ganisms may be viewed as a stimulus that maintains “low-grade”
matory or antiinflammatory/pro-repair properties. Inflamma- chronic inflammation and induces monocyte recruitment (91). In
tory monocytes, typically characterized as Gr1+Ly6Chi, CCR-2+, summary, monocytes migrate to sites of injury (92) and secrete
CX3CR-1lo in mice or CD14+, CD16 – in humans, are the major pop- soluble mediators that contribute to wound repair. While many
ulation of mononuclear cells initially recruited to sites of injury studies focus on macrophage functions in wound healing, the
(Figure 3). They are a potent source of proinflammatory cytokines importance of infiltrating monocytes in mediating key aspects of
such as IL-6 and TNF-α. Shortly after arrival of inflammatory skin and intestinal wound repair remains understudied.
monocytes into wound sites, monocytes with antiinflammatory Macrophages. Macrophages contribute to wound repair and
properties marked by expression of Gr1−Ly6Clo, CCR-2−, CX3CR-1hi tissue remodeling by clearing apoptotic neutrophils (efferocyto-
in mice and CD14lo, CD16+ in humans are observed. Antiinflam- sis) and helping to reduce autoimmune and chronic inflammato-
matory monocytes release pro-repair molecules such as VEGF and ry responses (92). These effector functions are achieved, in part,
IL-10, promoting cell proliferation and angiogenesis (Figure 2 and through secretion of cytokines, growth factors, and specialized
ref. 88). While precise mechanisms are unclear, differential che- pro-resolving mediators (SPMs) (93). Wound-associated macro-
moattractant signaling from CCR-2 versus CX3CR-1 may regulate phages undergo polarization, a process involving integration of
recruitment of proinflammatory versus pro-repair monocytes into complex signals from the microenvironment followed by commit-
murine healing wounds (89). However, it remains unclear wheth- ment to a functional program directed at restoring tissue homeo-
er infiltrated monocytes transition from a proinflammatory to an stasis. Polarization continuously changes throughout the phases
antiinflammatory phenotype before differentiating into macro- of wound healing. Historically, macrophage characterization
phages, or whether independent monocyte populations migrate was based on M1 (inflammatory) or M2 (antiinflammatory/pro-
from the blood and differentiate into these cell types. repair) phenotypes. M1 macrophages are induced by inflammatory

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stimuli such as lipopolysaccharide and, when stimulated, release sues as well as facilitating inflammatory responses and mediating
proinflammatory cytokines such as TNF-α, IL-1β, IL-6, IL-8, and repair following injury.
IL-12. In contrast, M2 macrophages are induced by IL-4/IL-13 as Macrophages in sites of injury are critical for skin and gut
well as IL-10. M2 macrophages release antiinflammatory/pro- wound repair. Such wound-associated macrophages (WAMs) are
repair molecules including TGF-β, IL-10, and SPMs such as mares- adaptive, highly dynamic cells that can rapidly respond to cues
ins, resolvins, and protectins (see ref. 94 for a detailed review on within wound microenvironments (Figure 3). Current observations
SPMs, and refs. 95, 96). It is increasingly appreciated that M1/M2 indicate that WAM phenotype is influenced by complex factors that
macrophage classification is oversimplified; substantial overlap in are incompletely understood, including wound size, tissue loca-
the responses of these two types of macrophages is undoubtedly tion, and stage of the inflammatory process (acute versus chronic).
due to intermediate or transitional stages of differentiation. In sup- Like other macrophages, WAMs can have varied M1/M2 pheno-
port of such “plasticity” in tissue macrophage responses, M1-type types depending on the inflammatory/repair microenvironment,
macrophages were shown to switch to an M2 phenotype depend- exhibiting characteristics of both proinflammatory and pro-repair
ing on the composition of the local extracellular milieu (97). Fur- macrophages (89). Given these observations, it is unsurprising that
thermore, M1/M2 macrophage classification is largely based on in current literature is inconsistent on the types of cytokines produced
vitro differentiation, and increasing evidence suggests that such by WAMs. Some studies report that WAMs are not an important
in vitro analyses do not accurately reflect the complexity of in vivo source of the antiinflammatory cytokine IL-10 in skin wounds,
macrophage plasticity and heterogeneity. Adding to the complex- whereas other groups demonstrate that both skin and gut WAMs
ity of macrophage classification, current evidence also suggests are active producers of IL-10 with pro-repair properties (110, 111).
that monocytes that have entered tissues differentiate into mac- Such discrepancies are likely related to the temporal nature of
rophages displaying varying M1- or M2-like characteristics (98). IL-10–dependent responses during wound repair. Supporting this
These observations and emerging evidence increasingly imply notion, analyses of WAM-mediated IL-10 production suggest that
that diverse macrophage populations mediate healing responses IL-10 is produced at very specific times during the wound repair
by releasing cytokines/chemokines, SPMs, proteases, and other process, indicating that variables including wound size profoundly
mediators to orchestrate host defense, proliferation, and migration influence macrophage cytokine production responses.
of wound-associated cells as well as matrix remodeling. Further Macrophages and other immune cells sense the metabolic
studies are needed to better understand the role(s) of specific tis- environment and modulate function, an activity referred to as
sue macrophage subsets during the stages of wound repair (99). immunometabolism (112). Sites of injury have a hypoxic micro-
Most tissues (including skin and intestine) contain macro- environment generated primarily by neutrophils consuming high
phages termed tissue-resident macrophages (TRMs). TRMs rep- levels of oxygen while producing ROS in response to injury (113).
resent a heterogeneous population of nonmigratory cells that Hypoxia also promotes increased HIF-1α expression in inflamma-
respond to injury or infection by sensing DAMPs. TRMs in the tory macrophages, which increases glycolytic enzyme expression
skin and gut are continuously replenished by blood monocytes and IL-1β synthesis (114). Balanced IL-1β release is important, as
(100–102). TRM phenotypic markers vary depending on tissue excess inflammasome signaling associated with IL-1β generation
location. In skin, they have surface expression of F4/80+, CD11b+, is linked to development of chronic wounds (115). Phagocytosis of
CD11clo, CD206+, MHCIIlo, Dectin-1+, CD301+, and Dectin-2+, cellular debris in association with IL-4 and IL-13 signaling facil-
while in intestine, their cell surface markers include CX3CR-1hi, itates dampening of inflammatory signals and initiation of the
F4/80+, CD11b+, CD11c+, and CD64+. Intestinal (and a subset proliferative phase of tissue repair (116). Glucose is an important
of dermal) MHCIIhi macrophages have been shown to originate source of energy for inflammatory macrophage–mediated clear-
from bone marrow monocytes. These macrophages lack capaci- ance of cellular debris that influences the proliferative phase in
ty for self-renewal and have an estimated half-life of 4 to 6 weeks wound repair. Importantly, glucose availability likely influenc-
(103). An interesting subset of resident macrophages are epider- es macrophage secretion of proinflammatory mediators such as
mal Langerhans cells. While Langerhans cells were historically IL-1β and TNF-α (117). Interestingly, pro-repair macrophages have
considered DCs, they are now believed to represent a specialized a highly oxidative metabolism, and therefore restoring oxygen lev-
subset of TRMs. Unlike dermal TRMs, Langerhans cells are self- els is important in achieving resolution of inflammation (118).
replicating and can migrate to lymph nodes to present antigens Regenerative responses are likely mediated, in part, by inti-
to T cells (104). Importantly, Langerhans cells were reported to mate physical contact between macrophages and epithelial cells
repopulate the epidermis during re-epithelialization of acute skin that promotes intestinal epithelial transcription of multiple pro-
wounds (105). Despite these observations, mechanisms regulat- repair genes, including Ccl-2, Cox-2, Igf-1, and Il-11 (Figure 3).
ing TRM-mediated wound repair are poorly understood, although Furthermore, since Cox-2 (encoding cyclooxygenase-2) is nec-
increasing reports implicate contributions of dermal TRMs to essary for SPM synthesis, macrophage-mediated “activation” of
homeostatic maintenance, renewal of skin appendages, epitheli- epithelial cells might contribute to the generation of SPMs (119).
al repair, and barrier recovery (106, 107). Important functions of Current evidence suggests that intestinal WAMs are required for
intestinal TRMs include scavenging bacteria, helping maintain amplification of colonic epithelial cell progenitors that contribute
Tregs, and promoting epithelial cell renewal via production of to wound repair. WAMs physically contact epithelial stem cells
IL-10 and prostaglandin E2 (89, 100, 108, 109). Taken together, located within crypts, resulting in secretion of pro-proliferative
current evidence supports an emerging concept of multiple roles and remodeling factors. Furthermore, recent evidence indicates
for TRMs, including maintenance of homeostasis in epithelial tis- that intestinal macrophages promote regenerative responses by

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integrating cues from mesenchymal stem cells, other immune at early and mid-stages of skin repair results in delayed wound clo-
cells, microbiota, and injured epithelia. Efficient colonic wound sure and decreased scar formation, while macrophage loss during
repair also depends on Trem2 signaling in WAMs, which skews later stages of repair did not affect healing. Depletion of macro-
cellular machinery toward a pro-repair phenotype (119, 120). phages at mid-stages of skin wound repair resulted in decreased
CD206+CD301b+ skin macrophages also produce the crucial VEGF-A and TGF-β1 expression, as well as reduced angiogenesis
pro-repair molecule TGF-β1, a potent inducer of fibroblast prolif- and repair. Consistent with these observations, it was noted that
eration and subsequent differentiation into myofibroblasts, lead- during mid-stages of repair, macrophages secrete substantial
ing to collagen deposition in the wound (121–125). WAMs also pro- amounts of VEGF-A and TGF-β1 (106). The above-mentioned
mote epithelial repair through release of IL-10 and PDGF-β (125). mouse models have not yet been used to study the role of macro-
Macrophages can also directly transition into fibrosis-promot- phages in orchestrating intestinal mucosal repair in vivo. Howev-
ing cells, secreting ECM components such as collagen (126). These er, analogous temporal changes in macrophage function are likely
macrophages, referred to as fibrocytes or M2a macrophages, are necessary for mucosal repair in the gut. These findings highlight
implicated in pathogenesis of skin scarring. Interactions between macrophages as critical to epithelial wound repair, displaying a
macrophages and fibroblasts are critical in determining whether dynamic capacity to polarize in response to environmental cues
wounds heal with or without scarring. Regulatory-like, or M2c, that change as wound healing progresses.
macrophages within remodeling skin wounds release proteases While we have discussed contribution of macrophages in
and phagocytose cellular debris and ECM to clean out wounds orchestrating wound repair, DCs are also implicated as important
and facilitate repair (127). In skin, WAMs are hypothesized to innate mediators of repair. This topic is discussed in previous pub-
synthesize several members of the EGF family, e.g., EGF, TGF-α, lications and reviews (142–144).
and heparin-bound EGF (EGF-HB), which enhance keratinocyte Therapeutic opportunities. Several studies have either target-
migration and proliferation, thereby promoting skin re-epitheli- ed neutrophils/macrophages or used these cells as tools as part
alization (128–132). Inactive EGF family members are tethered to of strategies to improve wound healing. Nevertheless, such ther-
the cell membrane and require MMP-mediated cleavage to signal. apeutic targeting of innate immune cells has been limited by
Therefore, WAMs likely indirectly activate these growth factors incomplete understanding of underlying mechanisms by which
by modulating MMP activity. IL-1, IL-6, TNF-α, and TGF-β also these cell populations regulate repair. Early research focusing on
promote re-epithelialization (133). Interestingly, in human kerati- promoting neutrophil apoptosis yielded promising results, but
nocytes, WAM-derived TNF-α promotes expression of genes asso- off-target cell death presented a challenge (145). Novel technol-
ciated with cell movement, division, and survival (134). Presently, ogies and drugs aided in the development of new strategies to
no studies highlight contributions of M2a and M2c macrophages promote wound repair by inducing resolution of inflammation
to repair in the intestine. Recent observations indicate that WAMs without reducing neutrophil recruitment. A recent study observed
in close proximity to wounded dermal and intestinal epithelial that neutrophils “retrotax,” or reverse-migrate, away from inflam-
cells (and underlying fibroblasts) play important roles in orches- matory sites when exposed to SPMs (146). Manipulating this pro-
trating matrix remodeling and wound repair. As such, aberrations cess could potentially improve healing as well as infection control.
in macrophage function at different stages of wound repair mark- Other studies showed potential “therapeutic benefit” through
edly contribute to persistence of excessive ECM, resulting in skin controlled delivery of leukocyte-derived SPMs. For example,
fibrosis and permanent scarring. nanoparticles containing neutrophil-derived microparticles with
Recently, further insights into the role of macrophages in aspirin-triggered resolvin D1 or lipoxin A4 analogs reduced neu-
wound repair have been gained from mouse models using deplet- trophil recruitment in murine peritonitis and accelerated keratino-
ed subsets of macrophages. Mice lacking the Spi-1 proto-oncogene cyte wound healing (147).
protein lack mature macrophages as well as functional neutrophils. Strategies to improve wound healing through increased mac-
Surprisingly, these mice lack a skin wound-healing defect but rath- rophage recruitment and polarization toward a pro-repair pheno-
er exhibit marked reduction in scar formation (135). In support type have also been investigated. Direct injection of IL-1β–acti-
of macrophages’ critical importance in skin wound repair, abla- vated macrophages into murine skin wounds increased VEGF-C
tion of macrophages impaired murine skin wound healing (136, production and improved wound repair (148). Furthermore, local
137). These studies support an important role of macrophages in GM-CSF application to dermal wounds resulted in increased
removing apoptotic neutrophils from wounds, thereby preventing WAMs and enhanced wound healing (149). Since the complex bio-
ongoing release of tissue-degrading enzymes. Furthermore, when molecular microenvironment within wounds plays a critical role
macrophages fail to appropriately clear apoptotic neutrophils, in regulating macrophage polarization, strategies to enhance pro-
there are persistently high levels of proinflammatory cytokines duction or delivery of pro-repair molecules have been explored.
and decreased local antiinflammatory and pro-repair mediators For example, glutamine-loaded hydrogels increased the rate of
in wounds (138–140). Depletion of macrophages was also shown wound closure and re-epithelialization in wounded skin. In this
to reduce myofibroblast differentiation, which is necessary to pro- study, collagen deposition within wounds was consistent with
mote wound contraction and accelerate skin wound healing (141). increased activity of alternatively activated macrophages (150).
Genetically engineered and inducible depletion models in Conversely, strategies targeting inhibition of alternative macro-
mice enable selective macrophage depletion at different stages phage activation and resulting Arg-1 activity may help prevent
of the healing process, providing insights into the role of macro- scarring and fibrosis by reducing excessive collagen deposition
phages at various stages of wound repair. Macrophage depletion (151). From these observations, it is clear that methods promot-

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R E V I E W S E R I E S : R E PA R AT I V E I M M U N O L O G Y The Journal of Clinical Investigation  

ing macrophage activity or polarization to a wound-healing phe- (158). To overcome challenges arising from species differences,
notype have considerable promise, further supported by multiple new approaches using transcriptomics, metabolomics, humanized
other reports employing mesenchymal stem cells, growth factors, mice, and simple human/animal models (such as the skin blister
and biomaterials to modulate macrophage phenotype, function, model) must be exploited to directly compare and contrast func-
and transcriptome (152–154). tional biology of immune cell subsets between species (159–161).
While this brief overview highlights increased mechanistic
Concluding remarks evidence of the role of epithelial cells, neutrophils, monocytes,
Repair of injured epithelial barriers is a highly regulated process and macrophages in orchestrating skin and intestinal wound
orchestrated by resident cells and spatiotemporal immune cell repair, it is also clear that many other cellular contributions remain
recruitment, which not only contributes to host defense but is understudied. Given the plethora of chronic diseases associated
vital for tissue homeostasis and wound repair. Temporal interplay with impaired wound-healing responses, much investigation
between immune cells and wound-associated cells, secreted pro- remains to facilitate design of new therapeutic approaches to pro-
teins, and lipids ensures efficient resolution of inflammation in mote repair of wounds in chronic diseases.
concert with epithelial repair. One caveat is that most wound-heal-
ing research is performed in animal models, raising the question Acknowledgments
of relevance to human health. Notably, the relative abundance of This work was supported by NIH grants (DK055679, DK089763,
circulating neutrophils and monocytes in the blood differs consid- and DK059888 to AN; and DK61739, DK72564, and DK79392 to
erably between humans (50%–70% neutrophils, 10% monocytes) CAP) and a Crohn’s and Colitis Foundation Senior Research Award
and mice (10%–25% neutrophils, 4% monocytes). However, many (544596 to JCB) and Career Development Award (544599 to MQ).
studies report similar dynamics of innate immune cell recruitment
to sites of injury in mice and humans. Furthermore, a similar prev- Address correspondence to: Charles A. Parkos, Department of
alence of activated neutrophils is observed in chronic nonhealing Pathology, University of Michigan Medical School, 4063 BSRB, 109
wounds of both species, highlighting the relevance of murine mod- Zina Pitcher Place, Ann Arbor, Michigan 48109-2200, USA. Phone:
els for studies of innate immune cell biology in wound healing (155– 734.763.6384; Email: [email protected]. Or to: Asma Nusrat,
157). Human and mouse mononuclear phagocytes lack overlapping Department of Pathology, University of Michigan Medical School,
phenotypic markers, a challenge that hinders the identification 4057 BSRB, 109 Zina Pitcher Place, Ann Arbor, Michigan 48109-
and characterization of homologous populations between species 2200, USA. Phone: 734.764.5712; Email: [email protected].

1. Dahlhamer JM, Zammitti EP, Ward BW, Wheaton mucosa after acid injury in vivo and in vitro. Gas- 20. Rohani MG, Parks WC. Matrix remodeling
AG, Croft JB. Prevalence of inflammatory bowel troenterology. 1987;92(6):1973–1986. by MMPs during wound repair. Matrix Biol.
disease among adults aged ≥ 18 years — United 11. Leoni G, Neumann PA, Sumagin R, Denning TL, 2015;44–46:113–121.
States, 2015. MMWR Morb Mortal Wkly Rep. Nusrat A. Wound repair: role of immune- 21. Li Y, Kilani RT, Rahmani-Neishaboor E, Jalili
2016;65(42):1166–1169. epithelial interactions. Mucosal Immunol. RB, Ghahary A. Kynurenine increases matrix
2. Kappelman MD, et al. Direct health care costs 2015;8(5):959–968. metalloproteinase-1 and -3 expression in cultured
of Crohn’s disease and ulcerative colitis in 12. Lotz MM, Nusrat A, Madara JL, Ezzell R, Wewer dermal fibroblasts and improves scarring in vivo.
US children and adults. Gastroenterology. UM, Mercurio AM. Intestinal epithelial restitu- J Invest Dermatol. 2014;134(3):643–650.
2008;135(6):1907–1913. tion. Involvement of specific laminin isoforms 22. Eto H, et al. Therapeutic potential of fibroblast
3. Baumgart DC, Sandborn WJ. Inflamma- and integrin laminin receptors in wound closure growth factor-2 for hypertrophic scars: upregula-
tory bowel disease: clinical aspects and of a transformed model epithelium. Am J Pathol. tion of MMP-1 and HGF expression. Lab Invest.
established and evolving therapies. Lancet. 1997;150(2):747–760. 2012;92(2):214–223.
2007;369(9573):1641–1657. 13. van der Flier LG, Clevers H. Stem cells, self- 23. Matsuno K, et al. The expression of matrix metal-
4. Rieder F, Brenmoehl J, Leeb S, Schölmerich J, renewal, and differentiation in the intestinal epi- loproteinase matrilysin indicates the degree of
Rogler G. Wound healing and fibrosis in intesti- thelium. Annu Rev Physiol. 2009;71:241–260. inflammation in ulcerative colitis. J Gastroenterol.
nal disease. Gut. 2007;56(1):130–139. 14. Peterson LW, Artis D. Intestinal epithelial cells: 2003;38(4):348–354.
5. Sen CK, et al. Human skin wounds: a major and regulators of barrier function and immune homeo- 24. Saarialho-Kere UK, Vaalamo M, Puolakkainen P,
snowballing threat to public health and the econ- stasis. Nat Rev Immunol. 2014;14(3):141–153. Airola K, Parks WC, Karjalainen-Lindsberg ML.
omy. Wound Repair Regen. 2009;17(6):763–771. 15. Burclaff J, Mills JC. Plasticity of differentiat- Enhanced expression of matrilysin, collagenase,
6. Sturm A, Dignass AU. Epithelial restitution and ed cells in wound repair and tumorigenesis, and stromelysin-1 in gastrointestinal ulcers. Am J
wound healing in inflammatory bowel disease. part II: skin and intestine. Dis Model Mech. Pathol. 1996;148(2):519–526.
World J Gastroenterol. 2008;14(3):348–353. 2018;11(9):dmm035071. 25. Enyedi B, Niethammer P. Mechanisms of
7. McCormack SA, Viar MJ, Johnson LR. Migration 16. Aragona M, et al. Defining stem cell dynamics epithelial wound detection. Trends Cell Biol.
of IEC-6 cells: a model for mucosal healing. Am J and migration during wound healing in mouse 2015;25(7):398–407.
Physiol. 1992;263(3 pt 1):G426–G435. skin epidermis. Nat Commun. 2017;8:14684. 26. Yamaguchi N, Mizutani T, Kawabata K, Haga H.
8. Nusrat A, Delp C, Madara JL. Intestinal epithelial 17. Sun BK, Siprashvili Z, Khavari PA. Advances Leader cells regulate collective cell migration via
restitution. Characterization of a cell culture model in skin grafting and treatment of cutaneous Rac activation in the downstream signaling of
and mapping of cytoskeletal elements in migrating wounds. Science. 2014;346(6212):941–945. integrin β1 and PI3K. Sci Rep. 2015;5:7656.
cells. J Clin Invest. 1992;89(5):1501–1511. 18. Gurtner GC, Werner S, Barrandon Y, Longaker 27. Moyer RA, Wendt MK, Johanesen PA, Turner JR,
9. Moore R, Carlson S, Madara JL. Rapid barrier MT. Wound repair and regeneration. Nature. Dwinell MB. Rho activation regulates CXCL12
restitution in an in vitro model of intestinal epi- 2008;453(7193):314–321. chemokine stimulated actin rearrangement and
thelial injury. Lab Invest. 1989;60(2):237–244. 19. Caley MP, Martins VL, O’Toole EA. Metallopro- restitution in model intestinal epithelia. Lab
10. Feil W, Wenzl E, Vattay P, Starlinger M, Soguk- teinases and wound healing. Adv Wound Care Invest. 2007;87(8):807–817.
oglu T, Schiessel R. Repair of rabbit duodenal (New Rochelle). 2015;4(4):225–234. 28. Babbin BA, et al. Annexin 2 regulates intestinal

2990 jci.org   Volume 129   Number 8   August 2019

The Journal of Clinical Investigation   R E V I E W S E R I E S : R E PA R AT I V E I M M U N O L O G Y

epithelial cell spreading and wound closure 46. Nathan C. Neutrophils and immunity: chal- mouse skin wound healing. J Invest Dermatol.
through Rho-related signaling. Am J Pathol. lenges and opportunities. Nat Rev Immunol. 1995;105(1):120–123.
2007;170(3):951–966. 2006;6(3):173–182. 65. Kanno E, et al. Wound healing in skin promoted
29. Hinrichs BH, et al. Serum smyloid A1 is an 47. Ley K, Laudanna C, Cybulsky MI, Nourshargh S. by inoculation with Pseudomonas aeruginosa
epithelial prorestitutive factor. Am J Pathol. Getting to the site of inflammation: the leukocyte PAO1: the critical role of tumor necrosis factor-α
2018;188(4):937–949. adhesion cascade updated. Nat Rev Immunol. secreted from infiltrating neutrophils. Wound
30. Leoni G, et al. Annexin A1, formyl peptide recep- 2007;7(9):678–689. Repair Regen. 2011;19(5):608–621.
tor, and NOX1 orchestrate epithelial repair. J Clin 48. Brazil JC, Parkos CA. Pathobiology of neu- 66. Frank JB, et al. In vivo effect of tumor necrosis
Invest. 2013;123(1):443–454. trophil-epithelial interactions. Immunol Rev. factor α on wound angiogenesis and epitheliza-
31. Miyoshi H, Ajima R, Luo CT, Yamaguchi TP, Stap- 2016;273(1):94–111. tion. Eur J Trauma. 2003;29(4):208–219.
penbeck TS. Wnt5a potentiates TGF-β signaling 49. Brinkmann V, et al. Neutrophil extracellular traps 67. Scapini P, et al. Neutrophils produce biologically
to promote colonic crypt regeneration after tissue kill bacteria. Science. 2004;303(5663):1532–1535. active macrophage inflammatory protein-3α
injury. Science. 2012;338(6103):108–113. 50. MacLeod AS, Mansbridge JN. The innate (MIP-3α)/CCL20 and MIP-3β/CCL19. Eur J
32. Bradford EM, et al. Epithelial TNF receptor sig- immune system in acute and chronic wounds. Immunol. 2001;31(7):1981–1988.
naling promotes mucosal repair in inflammatory Adv Wound Care (New Rochelle). 2016;5(2):65–78. 68. Le Borgne M, et al. Dendritic cells rapidly recruit-
bowel disease. J Immunol. 2017;199(5):1886–1897. 51. Kominsky DJ, Campbell EL, Colgan SP. Metabolic ed into epithelial tissues via CCR6/CCL20 are
33. Birkl D, et al. TNFα promotes mucosal wound shifts in immunity and inflammation. J Immunol. responsible for CD8+ T cell crosspriming in vivo.
repair through enhanced platelet activating factor 2010;184(8):4062–4068. Immunity. 2006;24(2):191–201.
receptor signaling in the epithelium. Mucosal 52. Campbell EL, et al. Transmigrating neutrophils 69. Kvedaraite E, et al. Tissue-infiltrating neutrophils
Immunol. 2019;12(4):909–918. shape the mucosal microenvironment through represent the main source of IL-23 in the colon of
34. Kim MH, et al. Dynamics of neutrophil infil- localized oxygen depletion to influence resolution patients with IBD. Gut. 2016;65(10):1632–1641.
tration during cutaneous wound healing and of inflammation. Immunity. 2014;40(1):66–77. 70. Zindl CL, et al. IL-22-producing neutrophils con-
infection using fluorescence imaging. J Invest 53. Furuta GT, et al. Hypoxia-inducible factor tribute to antimicrobial defense and restitution
Dermatol. 2008;128(7):1812–1820. 1-dependent induction of intestinal trefoil factor of colonic epithelial integrity during colitis. Proc
35. Kolaczkowska E, Kubes P. Neutrophil recruitment protects barrier function during hypoxia. J Exp Natl Acad Sci U S A. 2013;110(31):12768–12773.
and function in health and inflammation. Nat Rev Med. 2001;193(9):1027–1034. 71. Zhou G, et al. CD177+ neutrophils as functionally
Immunol. 2013;13(3):159–175. 54. Hong WX, et al. The role of hypoxia-inducible activated neutrophils negatively regulate IBD.
36. Williams IR, Parkos CA. Colonic neutrophils factor in wound healing. Adv Wound Care (New Gut. 2018;67(6):1052–1063.
in inflammatory bowel disease: double-edged Rochelle). 2014;3(5):390–399. 72. Denning TL, Parkos CA. Neutrophils enlist IL-22
swords of the innate immune system with protec- 55. Botusan IR, et al. Stabilization of HIF-1α is critical to restore order in the gut. Proc Natl Acad Sci
tive and destructive capacity. Gastroenterology. to improve wound healing in diabetic mice. Proc U S A. 2013;110(31):12509–12510.
2007;133(6):2049–2052. Natl Acad Sci U S A. 2008;105(49):19426–19431. 73. Medina-Contreras O, et al. Cutting edge: IL-36
37. Anderson DC, et al. The severe and moderate 56. Chen F, et al. Neutrophils promote amphiregulin receptor promotes resolution of intestinal dam-
phenotypes of heritable Mac-1, LFA-1 deficiency: production in intestinal epithelial cells through age. J Immunol. 2016;196(1):34–38.
their quantitative definition and relation to leu- TGF-β and contribute to intestinal homeostasis. 74. Dumoutier L, Lejeune D, Hor S, Fickenscher H,
kocyte dysfunction and clinical features. J Infect J Immunol. 2018;201(8):2492–2501. Renauld JC. Cloning of a new type II cytokine
Dis. 1985;152(4):668–689. 57. Zaiss DMW, Gause WC, Osborne LC, Artis D. receptor activating signal transducer and activa-
38. Bressenot A, Salleron J, Bastien C, Danese S, Emerging functions of amphiregulin in orches- tor of transcription (STAT)1, STAT2 and STAT3.
Boulagnon-Rombi C, Peyrin-Biroulet L. Com- trating immunity, inflammation, and tissue Biochem J. 2003;370(pt 2):391–396.
paring histological activity indexes in UC. Gut. repair. Immunity. 2015;42(2):216–226. 75. McGee HM, et al. IL-22 promotes fibroblast-
2015;64(9):1412–1418. 58. Ramirez H, Patel SB, Pastar I. The role of TGFβ mediated wound repair in the skin. J Invest Der-
39. Riley SA, Mani V, Goodman MJ, Dutt S, Herd ME. signaling in wound epithelialization. Adv Wound matol. 2013;133(5):1321–1329.
Microscopic activity in ulcerative colitis: what Care (New Rochelle). 2014;3(7):482–491. 76. Curtis VF, et al. Neutrophils as sources of
does it mean? Gut. 1991;32(2):174–178. 59. Buschke S, et al. A decisive function of transform- dinucleotide polyphosphates and metabo-
40. Geboes K, Riddell R, Ost A, Jensfelt B, Persson T, ing growth factor-β/Smad signaling in tissue mor- lism by epithelial ENPP1 to influence barrier
Löfberg R. A reproducible grading scale for histo- phogenesis and differentiation of human HaCaT function via adenosine signaling. Mol Biol Cell.
logical assessment of inflammation in ulcerative keratinocytes. Mol Biol Cell. 2011;22(6):782–794. 2018;29(22):2687–2699.
colitis. Gut. 2000;47(3):404–409. 60. Cox DA, Kunz S, Cerletti N, McMaster GK, Burk 77. Colgan SP, Eltzschig HK. Adenosine and hypoxia-
41. Mori R, Kondo T, Nishie T, Ohshima T, Asano RR. Wound healing in aged animals — effects of inducible factor signaling in intestinal injury and
M. Impairment of skin wound healing in locally applied transforming growth factor beta 2 recovery. Annu Rev Physiol. 2012;74:153–175.
β-1,4-galactosyltransferase-deficient mice with in different model systems. In: Steiner R, Weisz 78. Colgan SP. Neutrophils and inflammatory
reduced leukocyte recruitment. Am J Pathol. PB, Langer R, eds. Angiogenesis. Basel, Switzer- resolution in the mucosa. Semin Immunol.
2004;164(4):1303–1314. land; Birkhäuser: 1992;61:287–295. 2015;27(3):177–183.
42. Devalaraja RM, et al. Delayed wound healing 61. Gillitzer R, Goebeler M. Chemokines in cutaneous 79. Ivanov AI, Parkos CA, Nusrat A. Cytoskeletal
in CXCR2 knockout mice. J Invest Dermatol. wound healing. J Leukoc Biol. 2001;69(4):513–521. regulation of epithelial barrier function during
2000;115(2):234–244. 62. Theilgaard-Mönch K, Knudsen S, Follin P, Borre- inflammation. Am J Pathol. 2010;177(2):512–524.
43. Kuhl AA, et al. Aggravation of different types gaard N. The transcriptional activation program 80. Montesinos MC, et al. Adenosine promotes
of experimental colitis by depletion or adhe- of human neutrophils in skin lesions supports wound healing and mediates angiogenesis in
sion blockade of neutrophils. Gastroenterology. their important role in wound healing. J Immunol. response to tissue injury via occupancy of A(2A)
2007;133(6):1882–1892. 2004;172(12):7684–7693. receptors. Am J Pathol. 2002;160(6):2009–2018.
44. Zhang R, Ito S, Nishio N, Cheng Z, Suzuki H, 63. Sørensen OE, Cowland JB, Theilgaard-Mönch 81. Wang J, Hossain M, Thanabalasuriar A, Gunzer
Isobe K. Up-regulation of Gr1+CD11b+ population K, Liu L, Ganz T, Borregaard N. Wound heal- M, Meininger C, Kubes P. Visualizing the func-
in spleen of dextran sulfate sodium administered ing and expression of antimicrobial peptides/ tion and fate of neutrophils in sterile injury and
mice works to repair colitis. Inflamm Allergy Drug polypeptides in human keratinocytes, a conse- repair. Science. 2017;358(6359):111–116.
Targets. 2011;10(1):39–46. quence of common growth factors. J Immunol. 82. Hasenberg A, et al. Catchup: a mouse model
45. Lekstrom-Himes JA, Gallin JI. Immunodeficiency 2003;170(11):5583–5589. for imaging-based tracking and modulation
diseases caused by defects in phagocytes. N Engl 64. Feiken E, Rømer J, Eriksen J, Lund LR. Neutro- of neutrophil granulocytes. Nat Methods.
J Med. 2000;343(23):1703–1714. phils express tumor necrosis factor-alpha during 2015;12(5):445–452.

jci.org   Volume 129   Number 8   August 2019 2991

R E V I E W S E R I E S : R E PA R AT I V E I M M U N O L O G Y The Journal of Clinical Investigation  

83. Fridlender ZG, et al. Polarization of tumor-asso- 2012;13(8):753–760. 121. Desmoulière A, Geinoz A, Gabbiani F, Gabbi-
ciated neutrophil phenotype by TGF-β: “N1” ver- 103. Sheng J, Ruedl C, Karjalainen K. Most tissue- ani G. Transforming growth factor-β1 induces
sus “N2” TAN. Cancer Cell. 2009;16(3):183–194. resident macrophages except microglia are α-smooth muscle actin expression in granu-
84. Deshmane SL, Kremlev S, Amini S, Sawaya derived from fetal hematopoietic stem cells. lation tissue myofibroblasts and in quiescent
BE. Monocyte chemoattractant protein-1 Immunity. 2015;43(2):382–393. and growing cultured fibroblasts. J Cell Biol.
(MCP-1): an overview. J Interferon Cytokine Res. 104.Doebel T, Voisin B, Nagao K. Langerhans cells — 1993;122(1):103–111.
2009;29(6):313–326. the macrophage in dendritic cell clothing. Trends 122. Pakyari M, Farrokhi A, Maharlooei MK, Ghahary
85. Martins-Green M, Petreaca M, Wang L. Chemo- Immunol. 2017;38(11):817–828. A. Critical role of transforming growth factor β
kines and their receptors are key players in the 105. Stojadinovic O, Yin N, Lehmann J, Pastar I, Kirs- in different phases of wound healing. Adv Wound
orchestra that regulates wound healing. Adv ner RS, Tomic-Canic M. Increased number of Care (New Rochelle). 2013;2(5):215–224.
Wound Care (New Rochelle). 2013;2(7):327–347. Langerhans cells in the epidermis of diabetic foot 123. Nacu N, et al. Macrophages produce TGF-
86. Ishida Y, Gao JL, Murphy PM. Chemokine recep- ulcers correlates with healing outcome. Immunol β-induced (β-ig-h3) following ingestion of
tor CX3CR1 mediates skin wound healing by pro- Res. 2013;57(1-3):222–228. apoptotic cells and regulate MMP14 levels and
moting macrophage and fibroblast accumulation 106. Lucas T, et al. Differential roles of macrophages collagen turnover in fibroblasts. J Immunol.
and function. J Immunol. 2008;180(1):569–579. in diverse phases of skin repair. J Immunol. 2008;180(7):5036–5044.
87. Zigmond E, et al. Ly6C hi monocytes in the 2010;184(7):3964–3977. 124. Liu Y, et al. TGF-β1 promotes scar fibroblasts
inflamed colon give rise to proinflammatory 107. Davies LC, Jenkins SJ, Allen JE, Taylor PR. proliferation and transdifferentiation via up-reg-
effector cells and migratory antigen-presenting Tissue-resident macrophages. Nat Immunol. ulating MicroRNA-21. Sci Rep. 2016;6:32231.
cells. Immunity. 2012;37(6):1076–1090. 2013;14(10):986–995. 125. Shook B, Xiao E, Kumamoto Y, Iwasaki A, Hors-
88. Shi C, Pamer EG. Monocyte recruitment during 108. Dejani NN, et al. Intestinal host defense outcome ley V. CD301b+ macrophages are essential for
infection and inflammation. Nat Rev Immunol. is dictated by PGE. Proc Natl Acad Sci U S A. effective skin wound healing. J Invest Dermatol.
2011;11(11):762–774. 2018;115(36):E8469–E8478. 2016;136(9):1885–1891.
89. Brancato SK, Albina JE. Wound macrophages as 109. Denning TL, Wang YC, Patel SR, Williams IR, 126. Schnoor M, et al. Production of type VI collagen
key regulators of repair: origin, phenotype, and Pulendran B. Lamina propria macrophages and by human macrophages: a new dimension in
function. Am J Pathol. 2011;178(1):19–25. dendritic cells differentially induce regulatory macrophage functional heterogeneity. J Immu-
90. Tamoutounour S, et al. Origins and functional and interleukin 17-producing T cell responses. nol. 2008;180(8):5707–5719.
specialization of macrophages and of conven- Nat Immunol. 2007;8(10):1086–1094. 127. Hesketh M, Sahin KB, West ZE, Murray RZ.
tional and monocyte-derived dendritic cells in 110. Daley JM, Brancato SK, Thomay AA, Reichner Macrophage phenotypes regulate scar forma-
mouse skin. Immunity. 2013;39(5):925–938. JS, Albina JE. The phenotype of murine wound tion and chronic wound healing. Int J Mol Sci.
91. Ginhoux F, Jung S. Monocytes and macrophages: macrophages. J Leukoc Biol. 2010;87(1):59–67. 2017;18(7):E1545.
developmental pathways and tissue homeostasis. 111. Quiros M, et al. Macrophage-derived IL-10 medi- 128. Rheinwald JG, Green H. Epidermal growth
Nat Rev Immunol. 2014;14(6):392–404. ates mucosal repair by epithelial WISP-1 signal- factor and the multiplication of cultured
92. Elliott MR, Koster KM, Murphy PS. Effero- ing. J Clin Invest. 2017;127(9):3510–3520. human epidermal keratinocytes. Nature.
cytosis signaling in the regulation of macro- 112. O’Neill LA, Kishton RJ, Rathmell J. A guide to 1977;265(5593):421–424.
phage inflammatory responses. J Immunol. immunometabolism for immunologists. Nat Rev 129. Li Y, Fan J, Chen M, Li W, Woodley DT.
2017;198(4):1387–1394. Immunol. 2016;16(9):553–565. Transforming growth factor-alpha: a major
93. Kloc M, Ghobrial RM, Wosik J, Lewicka A, Lewicki 113. de Oliveira S, Rosowski EE, Huttenlocher A. Neu- human serum factor that promotes human
S, Kubiak JZ. Macrophage functions in wound heal- trophil migration in infection and wound repair: keratinocyte migration. J Invest Dermatol.
ing. J Tissue Eng Regen Med. 2019;13(1):99–109. going forward in reverse. Nat Rev Immunol. 2006;126(9):2096–2105.
94. Quiros M, Nusrat A. Saving problematic muco- 2016;16(6):378–391. 130. Schultz G, Rotatori DS, Clark W. EGF and TGF-α
sae: SPMs in intestinal mucosal inflammation 114. Tannahill GM, et al. Succinate is an inflammatory in wound healing and repair. J Cell Biochem.
and repair. Trends Mol Med. 2019;25(2):124–135. signal that induces IL-1β through HIF-1α. Nature. 1991;45(4):346–352.
95. Mantovani A, Sica A, Locati M. Macro- 2013;496(7444):238–242. 131. Marikovsky M, et al. Wound fluid-derived hepa-
phage polarization comes of age. Immunity. 115. Mirza RE, Fang MM, Ennis WJ, Koh TJ. Block- rin-binding EGF-like growth factor (HB-EGF) is
2005;23(4):344–346. ing interleukin-1β induces a healing-asso- synergistic with insulin-like growth factor-I for
96. Dalli J, Serhan C. Macrophage proresolving ciated wound macrophage phenotype and Balb/MK keratinocyte proliferation. J Invest Der-
mediators — the when and where. Microbiol improves healing in type 2 diabetes. Diabetes. matol. 1996;106(4):616–621.
Spectr. 2016;4(3):MCHD-0001-2014. 2013;62(7):2579–2587. 132. Shirakata Y, et al. Heparin-binding EGF-like
97. Cohen HB, Mosser DM. Extrinsic and intrinsic 116. Bosurgi L, et al. Macrophage function in tissue growth factor accelerates keratinocyte migration
control of macrophage inflammatory responses. repair and remodeling requires IL-4 or IL-13 with and skin wound healing. J Cell Sci.
J Leukoc Biol. 2013;94(5):913–919. apoptotic cells. Science. 2017;356(6342):1072–1076. 2005;118(pt 11):2363–2370.
98. Guilliams M, Mildner A, Yona S. Developmental 117. Freemerman AJ, et al. Metabolic reprogram- 133. Martinez FO, Helming L, Gordon S. Alternative
and functional heterogeneity of monocytes. ming of macrophages: glucose transporter 1 activation of macrophages: an immunologic
Immunity. 2018;49(4):595–613. (GLUT1)-mediated glucose metabolism drives functional perspective. Annu Rev Immunol.
99. Wynn TA, Vannella KM. Macrophages in tissue a proinflammatory phenotype. J Biol Chem. 2009;27:451–483.
repair, regeneration, and fibrosis. Immunity. 2014;289(11):7884–7896. 134. Banno T, Gazel A, Blumenberg M. Effects of tumor
2016;44(3):450–462. 118. Vats D, et al. Oxidative metabolism and PGC-1β necrosis factor-α (TNF-α) in epidermal keratino-
100.Shaw TN, et al. Tissue-resident macrophages attenuate macrophage-mediated inflammation. cytes revealed using global transcriptional profil-
in the intestine are long lived and defined Cell Metab. 2006;4(1):13–24. ing. J Biol Chem. 2004;279(31):32633–32642.
by Tim-4 and CD4 expression. J Exp Med. 119. Seno H, Miyoshi H, Brown SL, Geske MJ, Colon- 135. Martin P, et al. Wound healing in the PU.1 null
2018;215(6):1507–1518. na M, Stappenbeck TS. Efficient colonic mucosal mouse—tissue repair is not dependent on inflam-
101. Bain CC, et al. Constant replenishment from cir- wound repair requires Trem2 signaling. Proc Natl matory cells. Curr Biol. 2003;13(13):1122–1128.
culating monocytes maintains the macrophage Acad Sci U S A. 2009;106(1):256–261. 136. Goren I, et al. A transgenic mouse model of
pool in the intestine of adult mice. Nat Immunol. 120. Pull SL, Doherty JM, Mills JC, Gordon JI, Stappen- inducible macrophage depletion: effects of
2014;15(10):929–937. beck TS. Activated macrophages are an adaptive diphtheria toxin-driven lysozyme M-specific cell
102. Wang Y, et al. IL-34 is a tissue-restricted ligand element of the colonic epithelial progenitor niche lineage ablation on wound inflammatory, angio-
of CSF1R required for the development of necessary for regenerative responses to injury. genic, and contractive processes. Am J Pathol.
Langerhans cells and microglia. Nat Immunol. Proc Natl Acad Sci U S A. 2005;102(1):99–104. 2009;175(1):132–147.

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The Journal of Clinical Investigation   R E V I E W S E R I E S : R E PA R AT I V E I M M U N O L O G Y

137. Mirza R, DiPietro LA, Koh TJ. Selective and 146.Robertson AL, et al. A zebrafish compound 153. Barminko JA, Nativ NI, Schloss R, Yarmush ML.
specific macrophage ablation is detrimen- screen reveals modulation of neutrophil reverse Fractional factorial design to investigate stromal
tal to wound healing in mice. Am J Pathol. migration as an anti-inflammatory mechanism. cell regulation of macrophage plasticity. Biotech-
2009;175(6):2454–2462. Sci Transl Med. 2014;6(225):225ra29. nol Bioeng. 2014;111(11):2239–2251.
138. Daley JM, et al. Modulation of macrophage 147. Norling LV, Spite M, Yang R, Flower RJ, Per- 154. Self-Fordham JB, Naqvi AR, Uttamani JR, Kulkar-
phenotype by soluble product(s) released from retti M, Serhan CN. Cutting edge: humanized ni V, Nares S. MicroRNA: dynamic regulators of
neutrophils. J Immunol. 2005;174(4):2265–2272. nano-proresolving medicines mimic inflamma- macrophage polarization and plasticity. Front
139. Meszaros AJ, Reichner JS, Albina JE. Macro- tion-resolution and enhance wound healing. Immunol. 2017;8:1062.
phage-induced neutrophil apoptosis. J Immunol. J Immunol. 2011;186(10):5543–5547. 155. Doeing DC, Borowicz JL, Crockett ET. Gender
2000;165(1):435–441. 148. Maruyama K, Asai J, Ii M, Thorne T, Losordo DW, dimorphism in differential peripheral blood
140. Meszaros AJ, Reichner JS, Albina JE. Macrophage D’Amore PA. Decreased macrophage number and leukocyte counts in mice using cardiac, tail, foot,
phagocytosis of wound neutrophils. J Leukoc Biol. activation lead to reduced lymphatic vessel forma- and saphenous vein puncture methods. BMC Clin
1999;65(1):35–42. tion and contribute to impaired diabetic wound Pathol. 2003;3(1):3.
141. Bochaton-Piallat ML, Gabbiani G, Hinz B. The healing. Am J Pathol. 2007;170(4):1178–1191. 156. Mestas J, Hughes CC. Of mice and not men: dif-
myofibroblast in wound healing and fibrosis: 149. Fang Y, Shen J, Yao M, Beagley KW, Hambly BD, ferences between mouse and human immunolo-
answered and unanswered questions. F1000Res. Bao S. Granulocyte-macrophage colony-stimu- gy. J Immunol. 2004;172(5):2731–2738.
2016;5:F1000 Faculty Rev-752. lating factor enhances wound healing in diabetes 157. van Furth R, Sluiter W, van Dissel JT. Genetic
142. Strbo N, Yin N, Stojadinovic O. Innate and via upregulation of proinflammatory cytokines. control of macrophage responses. Ann N Y Acad
adaptive immune responses in wound epithe- Br J Dermatol. 2010;162(3):478–486. Sci. 1986;465:15–25.
lialization. Adv Wound Care (New Rochelle). 150. Thangavel P, Ramachandran B, Chakraborty S, 158. Reynolds G, Haniffa M. Human and mouse
2014;3(7):492–501. Kannan R, Lonchin S, Muthuvijayan V. Accelerat- mononuclear phagocyte networks: a tale of two
143. Haniffa M, Gunawan M, Jardine L. Human skin ed healing of diabetic wounds treated with l-glu- species? Front Immunol. 2015;6:330.
dendritic cells in health and disease. J Dermatol tamic acid loaded hydrogels through enhanced 159. van de Mortel JE, Aarts MG. Comparative tran-
Sci. 2015;77(2):85–92. collagen deposition and angiogenesis: an in vivo scriptomics — model species lead the way. New
144. Kadowaki T, Shimada M, Inagawa H, Kohchi C, study. Sci Rep. 2017;7(1):10701. Phytol. 2006;170(2):199–201.
Hirashima M, Soma G. Reconsideration of mac- 151. Campbell L, Saville CR, Murray PJ, Cruickshank 160. Shay T, et al. Conservation and divergence in
rophage and dendritic cell classification. Antican- SM, Hardman MJ. Local arginase 1 activity is the transcriptional programs of the human and
cer Res. 2012;32(6):2257–2261. required for cutaneous wound healing. J Invest mouse immune systems. Proc Natl Acad Sci U S A.
145. Rossi AG, et al. Cyclin-dependent kinase inhibi- Dermatol. 2013;133(10):2461–2470. 2013;110(8):2946–2951.
tors enhance the resolution of inflammation by 152. Hu MS, et al. Delivery of monocyte lineage cells 161. Jenner W, et al. Characterisation of leukocytes in
promoting inflammatory cell apoptosis. Nat Med. in a biomimetic scaffold enhances tissue repair. a human skin blister model of acute inflamma-
2006;12(9):1056–1064. JCI Insight. 2017;2(19):96260. tion and resolution. PLoS One. 2014;9(3):e89375.

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