Scoping Review: Evaluation of Moringa oleifera (Lam.) for Potential Wound Healing in In Vivo Studies

Thanks for the comments. Below are the changes we have made based on the Reviewer 1’s report:

1.     We have assessed the parameters used in the included studies and determined that Moringa oleifera is useful for acute wounds based on the data extracted. Therefore we have included this in the manuscript with added new reference to support this statement.

Line 254-258: The current findings from the included studies shows the potential of M. oleifera in acute wounds which consists of open wounds (incisional and excisional model) and closed wounds (dead space). It is recommended to investigate further its potential on non-healing wounds which is due to stalled inflammation phase and imbalance of proteases during tissue formation phase. [Masson‐Meyers, D. S., Andrade, T. A., Caetano, G. F., Guimaraes, F. R., Leite, M. N., Leite, S. N., & Frade, M. A. C. (2020). Experimental models and methods for cutaneous wound healing assessment. International journal of experimental pathology, 101(1-2), 21-37]

2.     We agree with this statement and have made the necessary changes by finding another suitable reference on the mortality rate of wounds at Line 36-40: There are many factors impacting wound healing such as oxygenation, infection, age and sex hormones, stress, diabetes, obesity, medications, alcoholism, smoking, and nutrition ². A five-year mortality study on patients with diabetic foot ulcers has shown a comparable mortality rate with cancer (30.5% vs 31%) indicating the impact of wounds to healthcare. [Armstrong D, Swerdlow M, Armstrong A, Conte M, Padula W, Bus SA. Five year mortality and direct costs of care for people with diabetic foot complications are comparable to cancer. J Foot Ankle Res 2020;13:16]

We have also remove reference no.7 and replaced with a new reference.

3.     We have included the phytochemical content as justification on doing this review paper at Line 63-66: The phytochemical content of  M. oleifera leaves consists of polyphenol, phenolic acids, vitamins, carotenoids,  isothiocyanates, tannins, saponins, flavonoids, alkaloids, glucosinolates, oxalates and phytates which are beneficial bioactive compounds. [Leone, A., Spada, A., Battezzati, A., Schiraldi, A., Aristil, J., & Bertoli, S. (2015). Cultivation, genetic, ethnopharmacology, phytochemistry and pharmacology of Moringa oleifera leaves: An overview. International journal of molecular sciences, 16(6), 12791-12835.]

4.     We have included studies that mentioned the non toxic nature and the affordability of herbal medicine as advantage for wound care treatment at Line 44-46: An ideal wound dressing should be non toxic and cost effective. Herbal medicine can be considered to have non toxic nature due to the long history of use and affordable. [Rezvani Ghomi, E., Khalili, S., Nouri Khorasani, S., Esmaeely Neisiany, R., & Ramakrishna, S. (2019). Wound dressings: Current advances and future directions. Journal of Applied Polymer Science, 136(27), 47738.] [Ekor M. The growing use of herbal medicines: Issues relating to adverse reactions and challenges in monitoring safety. Frontiers in Pharmacology. 2013;4:177]

5.     We have re-analysed the included study and updated the information required for placebo and standard. Line 190-195: Based on the results, the latest study by Ali et al (2021) ⁴² showed that the n-hexane extract of M. oleifera seeds administered topically to Swiss Albino mice exhibited the wound healing activity by achieved complete excision wound closure on 13^th day of treatment compared to control (carbopol hydrogel without M. oleifera extract; 70% wound contraction) and standard (5% povidone; 95% wound contraction) which remain unhealed.

6.     We have amended as suggested at Line 197-199 : The findings also showed that topical application of M. oleifera aqueous leaves extract is the most used intervention for wound healing compared to oral or application of other extracts.

7.     We have amended as suggested at Line 211-213: The right wound area humidity or appropriate moisture is also important to accelerate the formation of the growth factors and increase the fibroblast cell infiltration for wound healing ⁴⁹.

8.     We have amended as suggested at Line 251-253: Macrophage is a very active phagocyte that removes foreign bodies, microbes, have direct effect granular tissue development, as well as wound regulation, cellular activation via cytokines, and angiogenesis via growth factors ^{29, 62}.

9.     We have studied the applicability of animal models to represent the inflammation phase in human wounds. Therefore, we have included a sentence to show the challenges between animal and human model with the research gap analysis needed to further investigate and understand the role that Moringa oleifera can play in wound care management at Line 283-288: However, careful consideration of prolonged inflammation is not usually represented in animal models and therefore anti-inflammatory action may not be sufficient considering other factors such as the oxygen, nutrients, bacterial infection and cellular events. [Zomer, H.D.; Trentin, A.G. Skin wound healing in humans and mice: Challenges in translational research. J. Dermatol. Sci. 2018, 90, 3–12] Therefore, it is important to investigate these issues on human wounds measuring the pro-inflammatory and anti-inflammatory cytokine levels together with antioxidant and antimicrobial activities of the plant.

We have also updated the importance of further research to really determine the role of Moringa oleifera in wound management at Line 363-369: However, the exact phytochemical responsible and the formulation factor such as particle size and type of extract used need to be determined to comprehend the complete mechanism of wound healing activity by M. oleifera and its role either as a therapeutic agent, supplementation or combination therapy. Further studies also need to be conducted on other wound models and safety assessment to prevent the interferences of other therapeutic actions and unwanted adverse effects in order to yield the best wound healing efficacy.

10.  We have amended as suggested at Line 312-313: This review was conducted based on the primary question “What are the wound healing potentials of M. oleifera?”.

Thanks for the comments. Below are the changes we have made based on the Reviewer 2’s report:

1.     We have relate the results with the traditional uses based on the route of administration extracted from the included studies and its positive findings at Line 187-190: Our findings showed that the herbal plant M. oleifera has positive impacts on wound healing process when administered orally or topically which reflects its traditional use as leave paste for wound healing in India district²⁰.

2.     We understand the importance of knowing the composition of each interventions used in the included studies. Therefore, a detailed composition as well as qualitative, quantitative and standardization details of the herbal interventions was extracted into a table as S3 appendix. However, all the studies did not have clear information on the composition of the formulation  used  as intervention. This has been reported in the manuscript at Line 134-137

Thanks for the comments. Below are the changes we have made based on the Reviewer 3’s report:

1.     We have arranged Figure 1 as shown in page 3

2.     We have included the phytochemical content as justification on doing this review paper at Line 63-66: The phytochemical content of  M. oleifera leaves consists of polyphenol, phenolic acids, vitamins, carotenoids,  isothiocyanates, tannins, saponins, flavonoids, alkaloids, glucosinolates, oxalates and phytates which are beneficial bioactive compounds. [Leone, A., Spada, A., Battezzati, A., Schiraldi, A., Aristil, J., & Bertoli, S. (2015). Cultivation, genetic, ethnopharmacology, phytochemistry and pharmacology of Moringa oleifera leaves: An overview. International journal of molecular sciences, 16(6), 12791-12835.]